1. STICHTING BG

2. STICHTING MB AMSTERDAM 31-1-2056

3. PEPTIC ULCER

4. 1900 – 1950: increasing incidence 1930: 10-12 % of the population diagnosis by X-ray etiology: excess acidification by: infection (teeth,tonsils) stress/emotion:fear,horror deep disgust PEPTIC ULCER

6. Bertram Welton Sippy (1866–1924) was born in the village of Neptune in Richland County, Wisconsin. After 2 years at the University of Wisconsin he transferred to Rush Medical College in Chicago where he was awarded his MD degree in 1890. He took a job as a railroad surgeon in Montana in order to obtain funds for an 18-month tour of hospitals and clinics in Europe, including a stint with the famed Professor Carl Ewald in Berlin. On his return to Chicago he set up a practice of internal medicine, with an emphasis on neurology but without neglect of the broader field. He quickly acquired a reputation as an astute diagnostician and superb teacher. It is said his showmanship held his students spellbound and doubtlessly contributed to his success with patients. An ardent believer in Schwartz’ dictum (“No acid, no ulcer”), he promoted for the treatment of acute peptic ulcer disease a strict regimen of hourly milk and cream feedings supplemented by frequent, large doses of antacids and often by periodic gastric aspiration. A generation of physicians found this a highly effective means of hastening the healing of peptic ulcers. Unfortunately, the Sippy regimen did little to prevent ulcer recurrence, and Sippy’s program was later superceded by more efficacious therapy

7. Peptic ulcer epidemiology 1984 US: 1970-1978:decrease in hospitalization rates for DU,not for GU ● low rates in summer ? ● smoking,aspirin,steroids ● genetic factors Kurata JH 1984

8. Ulcer - 1984 EPIDEMIOLOGY peak around 1950: ca 8 % of the working population disease of middle-aged DU: male-female ratio 2-4/1 genetic influences: blood group 0 poorer part of the population war and social unrest: increased incidence tobacco,alcohol,ulcerogenic drugs

9. Copyright ©2001 BMJ Publishing Group Ltd. Logan, R. P H et al. BMJ 2001;323:920-922 No Caption Found Prevalence of H pylori infection by age in developing and developed countries

10. Risk factors for Helicobacter pylori infection Birth in a developing country Low socioeconomic status Crowded living conditions Large families Unsanitary living conditions Unclean food or water Presence of infants in the home Exposure to gastric contents of infected individuals

11. Peptic ulcer epidemiology 1994 5 known causative factors: ● Hp ● NSAID ● Cigarette smoking ● Environmental stress ● Dietary habit Lam SK 1994

12. Time-trends in the epidemiology of peptic ulcer bleeding per 100.000 person-yearsOhmann et al Scand J Gastroenterol 2005

13. Duodenal ulcer: the helicobacterization of a psychosomatic disease? Melmed RN, Gelpin Y Melmed RNGelpin Y Isr J Med Sci. 1996 Mar-Apr;32(3-4):211-6

14. Is Hp the primary cause of DU ? Arguments against: 1. Regional and ethnic differences in DU prevalence in countries with high prevalence of Hp 2. Prevalence of Hp-negative DU 3. DU-recurrence after Hp -eradication

15. Recurrent peptic ulcers after successful Hp-eradication Multicenter study: 4940 patients ● Ulcer recurrence (NSAIDs excluded): 1,9 % / year 84 % recurred at the same site as the previous ulcers Hiroto Miwa 2004

16. Hp-negative/NSAIDs-negative peptic ulcer prevalence ● different data: high in US, Asia and Australia low in Europe: Freston (USA) : 11 – 44 % (1) Kent-Man Chu (Hong Kong): 29,6 % of 1343 pat. (2) Arroyo (Spain) : 2,1 % of 754 pat. (3) Arents (Drente) : 4,9 % of 405 pat. (4) Xia (Australia) : 43 % (5) 1.Aliment Pharmacol Ther,2001 2.World J Gastroenterol 2005 3.Helicobacter 2004 4.Eur J Gastroenterol 2004 5.Drugs 1999

17. Hp-negative/NSAIDs-negative DU characteristics Compared with Hp-positive DU: - older age - more concomitant problems - pre-existing malignancy - recent surgery - underlying sepsis - relative acid hypersecretion - reduced efficacy of antisecretory drugs Kent-Man Chu,2005 Freston,2001 Hung,2005

18. Hung et al Gastroenterology 2005 Long-term outcome of Helicobacter-negative idiopathic bleeding ulcers:a prospective cohort study

19. Hung et al, 2005 Cumulative probability of recurrent ulcer bleeding in the group with Hp-negative idiopathic ulcers and the group with Hp-ulcers,who received eradication therapy

20. Peptic ulcer disease in patients with chronic liver disease Compared with the general population patients with cirrhosis have: ● higher bleeding complications ● delayed healing ● greater ulcer recurrence rates ● less benefit from Hp- eradication

21. The effects of eradication of Helicobacter pylori on the recurrence of duodenal ulcer in patients with cirrhosis Liver cirrhosis + DU: 102 patients ● Hp + : 54 (52%) ● Hp - : 50 (48%) Recurrence after 1 year: ● After Hp eradication: 21/36 58 % ● Hp+ after eradication: 8/18 44 % ● Hp - : 24/50 48 % Lo et al. Gastrointest Endosc 2005

22. Conclusions ● Peptic ulcer is still a multifactorial disease Hp and NSAIDs are not the only factors Idiopathic ulcers (Hp-neg,NSAID-neg) are difficult to treat Peptic ulcers in patients with liver cirrhosis are often not related to Hp

23. RTC: 20 horses: gastroscopy: no ulcer 10 horses: day 0:trailer transport to another site day 1-3: exercise day 4: transport back Gastroscopy day 5: gastric ulcer: 7 /10 10 horses: no transport Gastroscopy day 5: gastric ulcer: 2/10 Mc Clure,J Am Vet Med Assoc,2005