A Case Study: What Doses of Amanita phalloides and Amatoxins Are Lethal to Humans?

There are few data estimating the human lethal dose of amatoxins or of the toxin level present in ingested raw poisonous mushrooms. Here, we present a patient who intentionally ingested several wild collected mushrooms to assess whether they were poisonous. Nearly 1 day after ingestion, during which the patient had nausea and vomiting, he presented at the emergency department. His transaminase levels started to increase starting from hour 48 and peaking at hour 72 (alanine aminotransferase 2496 IU/L; aspartate aminotransferase 1777 IU/L). A toxin analysis was carried out on the mushrooms that the patient said he had ingested. With reversed-phase high-performance liquid chromatography analysis, an uptake of approximately 21.3 mg amatoxin from nearly 50 g mushroom was calculated; it consisted of 11.9 mg alpha amanitin, 8.4 mg beta amanitin, and 1 mg gamma amanitin. In the urine sample taken on day 4, 2.7 ng/mL alpha amanitin and 1.25 ng/mL beta amanitin were found, and there was no gamma amanitin. Our findings suggest that the patient ingested approximately 0.32 mg/kg amatoxin, and fortunately recovered after serious hepatotoxicity developed.

Can serum fetuin-A be regarded as an inflammatory marker among patients with familial Mediterranean fever?

BACKGROUND/AIM: Familial Mediterranean fever (FMF), the most frequent periodic fever syndrome, is an autosomal recessive inherited disease that predominantly affects eastern Mediterranean populations. Fetuin-A is a well known negative acute-phase protein. Studies of this glycoprotein as a marker of inflammation in FMF are limited. We have investigated the relationship between serum levels of fetuin-A and inflammatory markers in patients with FMF before, during, and after FMF attacks. METHODS: Sixty-seven patients with FMF were enrolled in this study. Serum fetuin-A, seruloplasmin, fibrinogen, C reactive protein (CRP), white blood cell count (WBC), calcium, and erythrocyte sedimentation rate (ESR) were measured three times: during the attack-free period, 12 h after FMF attacks, and 7 days after FMF attacks. Plasma fetuin-A concentration was measured by use of an enzyme-linked immunoassay (ELISA) kit. Correlations and differentiation between the serum fetuin-A and other inflammatory markers in patients with FMF were investigated by use of the paired-samples T test and the Pearson correlation test (p < 0.01). RESULTS: Serum fetuin-A levels of all FMF patients in the attack period were significantly lower than in the attack-free period (p < 0.001). In contrast, serum seruloplasmin (p < 0.05), fibrinogen (p < 0.001), CRP (p < 0.05), WBC (p < 0.05), and ESR (p < 0.05) were all significantly higher than in the attack-free period. Plasma fetuin-A is significantly and inversely highly correlated with the other inflammatory markers. CONCLUSION: Fetuin-A might be a novel indicator of disease activity in patients with FMF and could be used as an adjunctive marker for differentiation of FMF attacks. The negative correlation between serum fetuin-A and other inflammatory markers may also be indicative of inflammation-dependent downregulation of fetuin-A expression in FMF patients.

Effect of proton pump inhibitor (PPI) treatment in obstructive sleep apnea syndrome: an esophageal impedance-pHmetry study.

BACKGROUND/AIMS: There is an increasing interest for a link between gastroesophageal reflux (GER) and obstructive sleep apnea syndrome (OSAS). There is no study in the literature which examines the relationship between OSAS and esophageal functions in adults with impedance. We first evaluated the role of reflux in OSAS with simultaneous polysomnography and impedance-pHmetry and then investigated whether the effect of proton pump inhibitor (PPI) treatment changes in these parameters. METHODOLOGY: Twenty two OSAS patients who had applied to sleep laboratory between September 2007 and May 2008 were consecutively enrolled to the study. Twenty four hours esophageal impedance study was performed during polysomnographic recording. At least 50% of all apneas in patients must proceed with a reflux event in 2 minute intervals in order to be considered reflux related apnea patient. RESULTS: Pathologic reflux episodes were determined in 20 patients (8 were weakly acidic, 12 were acidic). Reflux dependent apnea was found in 6 patients. There was endoscopically esophagitis in all reflux related apnea patients. There was a negative correlation between initial mean SaO2 and gas reflux events at night (p=0.004, r =-0.588) and mixed reflux events at night (p=0.02, r=0.493). There was a statistically significant regression of AHI (apnea hypopnea index) after 3-months PPI treatment (p=0.012). CONCLUSIONS: Reflux may trigger apnea in some of the OSAS patients. Therefore, each OSAS patient must be inquired about esophageal and extraesophageal symptoms of reflux.

Second-line levofloxacin-based triple therapy's efficiency for Helicobacter pylori eradication in patients with peptic ulcer.

OBJECTIVES: First-line standard eradication efficacy with lansoprazole, amoxicillin and clarithromycin regressed over 10 years. The aim of this study was to evaluate the efficacy and tolerability of a levofloxacin-based regimen in patients with peptic ulcer after failure of the standard first-line H.pylori eradication therapy in a country with a high rate of infection. METHODS: A total of 91 peptic ulcer patients who were diagnosed H.pylori positive proven by rapid urease test and histology between November 2005 to March 2008 were given lansoprazole 30 mg bid, amoxicillin 1 g bid and clarithromycin 500 mg bid (LAC) for 14 days. After three months from the first line eradication treatment omeprazole 20 mg bid, levofloxacin 500 mg bid, amoxicillin 1 g bid (OLA) 7 day treatment regimen was recommended as a second-line therapy for 37 patients who failed at first-line standard triple therapy. RESULTS: Eradication rates for LAC regimen were found to be 57.14% (52/91) for intention to treat and 58.42% (52/89) for per protocol analysis. Eradication rates for OLA regimen were found to be 37.83% (14/37) for ITT and 41.17% (14/34) for PP analysis. CONCLUSION: OLA regimen eradication rate was successful only in 40% of patients who failed in the first-line eradication. New eradication treatment strategies must be performed, at least in Turkey.

Is portal hypertensive enteropathy an important additional cause of blood loss in portal hypertensive patients?

OBJECTIVE: Recently, mucosal changes of small bowel were defined by developing new imaging techniques including capsule endoscopy (CE) in portal hypertensive patients. However, the clinical impact of these changes is unknown. In this study, we aimed to determine the additional cause of blood loss in portal hypertensive patients. MATERIAL AND METHODS: A total of 444 portal hypertensive patients, hospitalized in our clinic between 2005 and 2007, were evaluated. Patients with obscure bleeding were enrolled to this prospective case-control study. CE was performed in 21 patients who met inclusion criteria. Gastroscopy, colonoscopy and computerized tomography/small bowel enema were performed in all patients. RESULTS: Fourteen cirrhotic and seven noncirrhotic portal hypertensive patients were enrolled to this study. Mean age of patients was 47.9±15.6 years, and 13 of 21 were male. Small bowel varices were found in 7 patients (1 active bleeding) and other mucosal abnormalities in 10 patients (vascular ectasia, erosion and edema, 1 active bleeding). Although two of them were normal, jejunal malignant mass was found in two patients (1 active bleeding). Of 21 patients, 19 (90.5%) patients had portal hypertensive abnormalities (including varices). However, ileal varices rate was 57.1% (4 patients) in noncirrhotic portal hypertensive patients and 21.4% (3 patients) in cirrhotics. CONCLUSION: Ninety percent of patients had portal hypertensive abnormalities in small bowel and one-third of them had small bowel varices. Small bowel varices and vascular ectasia were the main causes of obscure bleeding in portal hypertensive patients.

Benign recurrent intrahepatic cholestasis: late initial diagnosis in adulthood.

Benign recurrent intrahepatic cholestasis (BRIC) is a rare autosomal recessive or sporadic disorder, characterized by recurrent episodes of intense pruritus and jaundice that resolve spontaneously without leaving considerable liver damage. The attacks can start at any age, but the first attack is usually seen before the second decade of life. We report the case of a young adult male patient with BRIC who presented with recurrent cholestatic jaundice and pruritus with negative work up for all possible etiologies and a liver biopsy consistent with intrahepatic cholestasis. He improved on treatment with rifampicin and has not suffered another attack on follow up. Although in adulthood, BRIC diagnosis should be kept in mind in patients with recurrent cholestatic attacks with symptom free intervals after main bile duct obstruction and other congenital or acquired causes of intrahepatic cholestasis excluded.

Epidemiologic features of inflammatory bowel disease in Western Blacksea region of Turkey for the last 10 years: retrospective cohort study.

BACKGROUND/AIMS: There are only a few epidemiological study about inflammatory bowel disease in the last 10 years in Turkey, especially in Western Blacksea region. In our study, we aimed to identify the changes in the incidence and the prevalence of inflammatory bowel disease in Western Blacksea region at the last 10 years. METHODS: Totally 223 patients with inf lammatory bowel disease (160 ulcerative colitis, 63 Crohn's disease) were enrolled in the study followed up between 2004 to 2013 years. The epidemiological characteristics of patients were recorded. RESULTS: The prevalences were 12.53/105 and 31.83/105 for Crohn's disease and ulcerative colitis respectively. Mean annual incidences increased from 0.99/105 and 0.45/105 for ulcerative colitis and Crohn's disease (2004 to 2005 years) to 4.87/105 and 2.09/105 for ulcerative colitis and Crohn's disease respectively (2011 to 2013 years). While the prevalence was higher in urban areas in Crohn's disease (12.60/105 ), it was higher in rural areas in ulcerative colitis (36.17/105 ). In ulcerative colitis, mean annual incidences were 2.91/105 and 2.86/105 for urban and rural areas respectively. In Crohn's disease, they were 1.37/105 and 1.08/105 for urban and rural areas respectively. CONCLUSION: The incidence of inflammatory bowel disease seems to increase in Western Blacksea region at the last 10 years. This increment is more prevalent in rural areas.

New treatment strategies for hepatitis C infection.

Hepatitis C infection can lead to cirrhosis and hepatocellular carcinoma and it is an important cause of mortality and morbidity. Achieving a sustained virological response has been the major aim for decades. Interferon treatment was the primarily developed therapy against the infection. Addition of the guanosine analog ribavirin to stop viral RNA synthesis increased the response rates as well as the adverse effects of the treatment. The increasing demands for alternative regimens led to the development of direct-acting antivirals (DAAs). The approval of sofosbuvir and simeprevir signaled a new era of antiviral treatment for hepatitis C infection. Although the majority of studies have been performed with DAAs in combination with interferon and resulted in a decrease in treatment duration and increase in response rates, the response rates achieved with interferon-free regimens provided hope for patients ineligible for therapy with interferon. Most DAA studies are in phase II leading to phase III. In the near future more DAAs are expected to be approved. The main disadvantage of the therapy remains the cost of the drugs. Here, we focus on new treatment strategies for hepatitis C infection as well as agents targeting hepatitis C virus replication that are in clinical development.

Current Helicobacter pylori treatment in 2014.

Helicobacter pylori is one of the most commonly seen bacterium worldwide. It's in the etiology of multiple gastrointestinal diseases, ranging from gastritis to gastric carcinoma. The antimicrobial therapies, which are frequently prescribed empirically, are losing their effectivity as a result of the increasing antimicrobial resistance. As the standard triple therapy is now left especially in areas with high-clarithromycin resistance due to decreased eradication rates, quadruple therapies are recommended in most regions of the world. Alternatively, concomitant, sequential and hybrid therapies are used. There is still a debate going on about the use of levofloxacin-based therapy in order to prevent the increase in quinolone resistance. If no regimen can achieve the desired eradication rate, culture-guided individualized therapies are highly recommended. Probiotics, statins and n-acetylcysteine are helpful as adjuvant therapies in order to increase the effectiveness of the eradication therapy. Herein, we focused on different eradication regimens in order to highlight the current Helicobacter pylori treatment.

Gastroesophageal reflux in asymptomatic obese subjects: An esophageal impedance-pH study.

AIM: To investigate the relationship between reflux and body mass index (BMI) in the asymptomatic obese population using the impedance-pH technique. METHODS: Gastroesophageal reflux is frequent in the obese population. However, the relationship between acid reflux and BMI in asymptomatic obese people is unclear. Forty-six obese (BMI > 25 kg/m(2)) people were enrolled in this prospective study. We evaluated the demographic findings and 24-h impedance pH values of the whole group. Gas, acid (pH < 4), weak acid (pH = 4-7) and weak alkaline (pH ≥ 7) reflux parameters were analyzed. RESULTS: The mean age of patients was 49.47 ± 12.24 years, and half of them were men. The mean BMI was 30.64 ± 3.95 kg/m(2) (25.14-45.58 kg/m(2)). BMI of 23 was over 30 kg/m(2). Seventeen patients had a comorbidity (hypertension, diabetes mellitus, or ischemic heart disease). Endoscopic examination revealed esophagitis in 13 of the 28 subjects (10 Grade A, 3 Grade B). The subjects were divided into two groups according to BMI (< 30 and > 30 kg/m(2)). Demographic and endoscopic findings, and impedance results were similar in these two groups. However, there was a positive correlation between BMI and total and supine pH < 4 episodes (P = 0.002, r = 0.414; P = 0.000, r = 0.542), pH < 4 reflux time (P = 0.015, r = 0.319; P = 0.003, r = 0.403), and DeMeester score (P = 0.012, r = 0.333). CONCLUSION: Acid reflux is correlated with BMI in asymptomatic obese individuals.

Osteoblastic metastasis from signet ring cell gastric cancer in a young male.

Bone metastasis is common in patients with lung, prostate, and breast cancers but it isn't common in stomach cancer. Gastric carcinoma infrequently metastasizes to the bone and rarely in an osteoblastic form. Herein we presented a rare case of signet ring cell gastric adenocarcinoma in early stage with osteoblastic metastasis. To our knowledge our case was the youngest signet cell gastric cancer patient with osteoblastic bone metastasis reported in literature.

Durability of sustained virologic response in chronic hepatitis C.

BACKGROUND/AIMS: The aim of this study is to investigate the rate of sustained virologic response (SVR) in chronic hepatitis C patients receiving antiviral treatment. METHODS: The files of patients with chronic hepatitis C treated with interferon±ribavirin between 1995 and 2009 were reviewed retrospectively. Six months after the end of treatment, patients with negative hepatitis C virus (HCV)-RNA (<50 IU/mL, as determined by the polymerase chain reaction method) were enrolled in the study. RESULTS: The mean age of 196 patients (89 males) was 46.13±11.10 years (range, 17 to 73 years). In biopsies, the mean stage was 1.50±0.94; histological activity index was 7.18±2.43. In total, 139 patients received pegylated interferon (IFN)+ribavirin, 21 patients received classical IFN+ribavirin, and 36 patients received IFN alone. The HCV genotypes of 138 patients were checked: 77.5% were genotype 1b, and 22.5% were other genotypes. After achievement of SVR, the median follow-up period was 33.5 months (range, 6 to 112 months), and in this period relapse was only detected in two patients (1.02%) at 18 and 48 months after treatment. CONCLUSIONS: In total, 98.9% of patients with SVR in chronic hepatitis C demonstrated truly durable responses over the long-term follow-up period of 3 years; relapsed patients had intermittent or low-grade viremia.

The investigation of effects of fluorosis on thyroid volume in school-age children.

AIM: To compare the urine iodine, fluoride, and to measure thyroid volumes in 10-15-year-old children using ultrasonography, a gold standard in evaluating thyroid volume. METHODS: A total of 261 children were enrolled into the study group from the 4-8th grades of 3 different primary schools, which were in the zone with high fluoride levels. The control group was formed by enrolling 298 children from the 4-8th grades of only one primary school. Age, gender, height, and weight values were recorded for the children. The urine iodine, fluoride, and thyroid volumes were measured with ultrasonography in 10-15-year-old children with fluorosis and controls and compared between two groups. RESULTS: The mean urine fluoride level was 0.48±0.24 mg/L in the study group and 0.22±0.17 mg/L in the control group (p < 0.001). The mean urine iodine level did not differ between two groups. The mean total thyroid volume was 8.60±3.11 mL and 8.73± 2.75 mL in the study and control group, respectively. The groups were also compared according to the echobody index, and the score was 6.94±2.14 ml/m² in the study group and 6.48±1.53 ml/m² in the control group (p=0.003). Mean thyroid volumes did not differ between two groups. However, the echobody index in the study group was higher than in the control group. CONCLUSION: A relation between fluoride concentration and thyroid gland with ultrasonographic examination was firstly evaluated, and it was concluded that fluoride affected thyroid gland although it was weakly significant. After puberty, echobody index in subjects with fluorosis was markedly high. Based on our results, we thought that fluorosis increases thyroid volume in children with fluorosis after puberty.

Co-infection with hepatitis B does not alter treatment response in chronic hepatitis C.

BACKGROUND/AIM: To investigate the clinical features and treatment response in patients with hepatitis B (HBV) and hepatitis C virus (HCV) co-infection receiving anti-HCV therapy. PATIENTS AND METHOD: Patients with HBV/HCV co-infection, who were eligible for anti-HCV therapy, were included in the study. Patients had detectable HBsAg for at least 6 months and detectable HCV-RNA before the initiation of therapy. Primary end-point was the proportion of patients achieving sustained virological response (SVR). HBV serology and HBV-DNA results obtained during the follow-up were assessed to determine HBV clearance or reactivation after anti-HCV therapy. RESULTS: There were 612 patients in the HCV cohort and 52 (8.5%) of them were HBV/HCV co-infected. Twenty-eight patients (20 male, mean age: 47 ± 12) received anti-HCV treatment and followed-up for a mean duration of 53 months (12-156). Fifteen patients received peginterferon/ribavirin combination while the remaining patients received standard interferon/ribavirin combination (n=6) or standard interferon monotherapy (n=7). Patients receiving interferon monotherapy were under chronic hemodialysis therapy. SVR was achieved in 14 (50%) patients at the end of follow-up. The proportion of patients with SVR in three treatment arms were not significantly different (P=0.78). Eight of 11 patients with detectable HBV-DNA cleared HBV-DNA during treatment. Seven (25%) patients experienced a rebound in HBV-DNA, and one patient experienced an acute hepatitis flare which was controlled by tenofovir therapy. Two (7%) patients cleared HBsAg and one of them was seroconverted to anti-HBs. CONCLUSION: Co-infection with HBV does not have a negative impact on the efficacy of anti-HCV treatment, but HBV-DNA should be monitored to overcome the risk of HBV exacerbation.

The prevalence of fibromyalgia among patients with hepatitis B virus infection.

Fibromyalgia (FM) is a syndrome characterized by widespread and chronic musculoskeletal pain, fatigue, morning stiffness, and sleep disturbance. However, the etiopathogenesis of FM remains unclear. Various etiological factors have been suggested to trigger FM. These include systemic rheumatismal disease, physical trauma, psychological disorders, and chronic infections. We determined the prevalence of FM in patients with chronic active hepatitis B virus (HBV) and inactive hepatitis B carriers, compared with matched healthy controls. Seventy-seven HBV patients (39 HBV carriers and 38 with chronic active hepatitis), were evaluated for FM syndrome. Seventy-seven HBsAg-negative healthy subjects were enrolled as a control group. We found that FM was very prevalent in patients with HBV infections (22% of the total). We found no difference in FM prevalence when patients with chronic active hepatitis B infections (21% FM prevalence) and those who were inactive hepatitis B carriers (23% FM prevalence) were compared. FM was not associated with the levels of HBV-DNA, ALT, or AST. Recognition and management of FM in HBsAg-positive patients will aid in improvement of quality-of-life. We fully accept that our preliminary results require confirmation in studies including larger numbers of patients. More work is needed to allow us to understand the role played by, and the relevance of, infections (including HBV) in FM syndrome pathogenesis.

Preliminary evidence of a reduced serum level of fibroblast growth factor 19 in patients with biopsy-proven nonalcoholic fatty liver disease.

OBJECTIVES: We sought to determine whether serum concentrations of fibroblast growth factor 19 (FGF19) - an ileum-derived enterokine which plays a role in the control of glucose and lipid homeostasis - are altered in patients with biopsy-proven nonalcoholic fatty liver disease (NAFLD). DESIGN AND METHODS: Serum levels of FGF19 were measured using enzyme-linked immunosorbent assay in 91 patients with biopsy-proven NAFLD and 74 controls. RESULTS: FGF19 levels were significantly lower in patients with biopsy-proven NAFLD (median: 130pg/mL) than in controls (median: 210pg/mL, P<0.001). Serum FGF19 levels were significantly but modestly associated with hepatocyte ballooning scores in univariate analysis (r=-0.25, P<0.05) but not after adjustment for potential confounders (ß=-0.18; t=1.78, P=0.08). CONCLUSIONS: This pilot study suggests that serum FGF19 levels are decreased in patients with NAFLD but are not independently associated with liver histology findings.

Does Cholecystectomy Increase the Esophageal Alkaline Reflux? Evaluation by Impedance-pH Technique.

BACKGROUND/AIMS: The aim of this study is to investigate the reflux patterns in patients with galbladder stone and the change of reflux patterns after cholecystectomy in such patients. METHODS: Fourteen patients with cholecystolithiasis and a control group including 10 healthy control subjects were enrolled in this prospective study. Demographical findings, reflux symptom score scale and 24-hour impedance pH values of the 14 cholecystolithiasis cases and the control group were evaluated. The impedance pH study was repeated 3 months after cholecystectomy. RESULTS: Age, gender, and BMI were not different between the two groups. Total and supine weakly alkaline reflux time (%) (1.0 vs 22.5, P = 0.028; 201.85 vs 9.65, P = 0.012), the longest episodes of total, upright and supine weakly alkaline reflux mediums (11 vs 2, P = 0.025; 8.5 vs 1.0, P = 0.035; 3 vs 0, P = 0.027), total and supine weakly alkaline reflux time in minutes (287.35 vs 75.10, P = 0.022; 62.5 vs 1.4, P = 0.017), the number of alkaline reflux episodes (162.5 vs 72.5, P = 0.022) were decreased with statistical significance. No statistically significant difference was found in the comparison of symptoms between the subjects in the control group and the patients with cholecystolithiasis, in preoperative, postoperative and postcholecystectomy status. CONCLUSIONS: Significant reflux symptoms did not occur after cholecystectomy. Post cholecystectomy weakly alkaline reflux was decreased, but it was determined that acid reflux increased after cholecystectomy by impedance pH-metry in the study group.

Indications, complications and long-term follow-up of patients undergoing percutaneous endoscopic gastrostomy: A retrospective study.

INTRODUCTION: Gastroenterology units have faced a major increase in referrals for PEG insertion over the last decade. For this reason we decided to review our PEG insertion procedures with regard to indications, complications and follow-up. MATERIALS AND METHODS: The indications, success of procedure, complications, long-term results of PEG in patients of Gulhane Military Medical Academy, Haydarpasa Training Hospital between October 2002 and April 2009 were retrospectively evaluated. RESULTS: 81 patients had undergone PEG insertion and follow-up information has been available for 77 patients. 40 were men with the mean age of all patients 70.74 ± 20.82 (range 20 to 104 years). PEG was successfully placed in all patients except in one patient who had gastric bleeding during the procedure. There was only one mortality related with the placement procedure. The most common indication for PEG was neurologic disorders in 71 (92%) patients. Other indications were head and neck cancers in 6 (8%) patients. Median follow-up period was 12 months (range, 3 days to 78 months). PEG related complications were seen in only 14 patients (18.2%) in 16 events with a total complication rate as 21%. CONCLUSIONS: PEG placement is a safe procedure and well-tolerated with a low mortality and complication rate even in older patients who have multiple co-morbidities under adequate precautions.

Etiological factors of duodenal and gastric ulcers.

BACKGROUND/AIMS: We aimed to determine the etiology of patients with duodenal and gastric ulcers. METHODS: 140 patients diagnosed with peptic ulcer between April 2002-2009 were enrolled in this prospective study. Two biopsy specimens were collected from the antrum and corpus for histology and one for rapid urease testing, and stool samples were analyzed for Helicobacter pylori antigen. Serum calcium and gastrin levels were also analyzed. RESULTS: 82 (58%) patients were male, with a median age of 47.70±15.03 years (range: 16-92). The ulcer was located in the duodenum in 96 patients, stomach in 40, and both duodenum and stomach in 4. The rates of patients positive for Helicobacter pylori antigen in stool, positive in urease testing and positive for Helicobacter pylori presence in antral and corpus samples were 48%, 52%, 67%, and 60%, respectively. 107 (76%) patients were positive for Helicobacter pylori in one of the test methods. 64 (46%) patients had a history of nonsteroidal antiinflammatory drug use within the last month. Mean levels of calcium and gastrin were 9.29±0.40 (7.90-10.20) and 73.96±89.88 (12.86-562.50), respectively. Gastrin level was correlated to inflammatory activity (p<0.05). 19 (13.6%) of the patients were negative for Helicobacter pylori, nonsteroidal anti- inflammatory drug use and hypersecretory illness, and were classified as idiopathic. CONCLUSIONS: The most common cause of duodenal and gastric ulcer was Helicobacter pylori, and it was responsible for three-fourths of the cases. About half of the patients had a history of nonsteroidal antiinflammatory drug use, and nonsteroidal antiinflammatory drug and Helicobacter pylori were both responsible for the ulcer in three-fourths of these patients. In about one-tenth of the patients, nonsteroidal antiinflammatory drug use was the cause of ulcer alone, and about one-tenth of the ulcers were classified as idiopathic.