Homeopathy Peptic Ulcers

Beat Ulcers

The system is all natural and easy to use. You are just minutes away from taking your first steps to having painless days and nights. In less than 2 weeks, you can be totally free from ulcers, living without the pain and feeling free to eat without the thought of pain. All you need do is follow the plan. Beat Ulcers is a step by step guide that shows you how you can eliminate ulcers in as little as 10 days. All you need do is use the readily available natural products in the correct proportions at the correct times. Here is what you will learn in the Beat Ulcers guide: How to Eliminate an Ulcer without the use of medication. How to rid your body of the ulcer causing bacteria and keep it away. How to stop the aching. How to eliminate the burping and bloating. Focus on the root cause of ulcers rather than the symptoms. How to be totally free from pain and sleep soundly at night. How to stop using dangerous medications that are prescribed over and over. Learn the causes of ulcers and how to eliminate them forever.

Beat Ulcers Summary

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Peptic Ulcer Disease

H. pylori plays an important role in the pathogenesis of idiopathic peptic ulcer disease. H. pylori infection can be diagnosed in 90-100 of duodenal ulcer patients and in 60-100 of gastric ulcer patients (15). The estimated risk of developing peptic ulcer disease during long-term follow-up of H. pylori-infected subjects varies between 10 and 20 (15). However, it remains unclear how or why ulcers develop, although variability among bacterial strain virulence and host defense, as well as environmental and dietary factors, may influence the pathogenesis. Eradication of H. pylori results in a marked decrease in the recurrence rates of duodenal and gastric ulceration (16,17) and improved quality of life of the patients (18). Excluding those taking aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), recurrence of these diseases is completely prevented for at least 9 years after successful H. pylori eradication (19).

Case 13 Pneumoperitoneum Due To Perforated Peptic Ulcer

Perforated Peptic Ulcer

The CXR shows free air under the right hemidiaphragm, in addition to features of hyperinflation. The possibilities include perforated peptic ulcer or GI malignancy, recent laparoscopy laparotomy, and peritoneal dialysis. It is important to do an erect CXR for the free air to rise to the top of the abdomen. For patients with a nasogastric tube in place, instillation of 200 ml of free air before the CXR may aid the diagnosis.

Gastritis and Peptic Ulcers

Peptic ulcers are erosions of the mucous membranes of the stomach or duodenum produced by the action of HCl. In Zollinger-Ellison syndrome, ulcers of the duodenum are produced by excessive gastric acid secretion in response to very high levels of the hormone gastrin. Gastrin is normally produced by the stomach but, in this case, it may be secreted by a pancreatic tumor. This is a rare condition, but it does demonstrate that excessive gastric acid can cause ulcers of the duodenum. Ulcers of the stomach, however, are not believed to be due to excessive acid secretion, but rather to mechanisms that reduce the barriers of the gastric mucosa to self-digestion. It has been known for some time that most people who have peptic ulcers are infected with a bacterium known as Helicobacter pylori, which resides in the gastrointestinal tract of almost half the adult population worldwide. Also, clinical trials have demonstrated that antibiotics that eliminate this infection help in the treatment of...

The Epidemiology and Pathophysiology of Gastroesophageal Reflux Disease

The role of Helicobacter pylori in GERD deserves special attention given the striking inverse time trends in the prevalence of GERD and H. pylori related peptic ulcer disease.11 Epidemiological data reveal that GERD patients with esophagitis are less likely to have H. pylori infection.12 H. pylori infection is also associated with a decreased prevalence of Barrett's metaplasia and esophageal adenocarcinoma.1315 Thus, epidemiological data clearly suggest a relationship between H. pylori and GERD. However, the details of that relationship are strongly dependent on the associated pattern of gastritis. If the dominant H. pylori strains within a population primarily result in corpus-dominant gastritis as in Japan,14 the prevalence of GERD in that population will be lower than it would be in the absence of H. pylori infection. These epidemiological data have led some to believe that H. pylori should not be eradicated in patients with GERD. However, H. pylori is a risk factor for the...

History of Medical and Surgical Anti Reflux Therapy

Humans have no doubt suffered from the symptoms and complications of gastroesophageal reflux disease (GERD) for millennia. However, recognition of a relationship between acid-pepsin and foregut disorders is relatively recent. The powerful digestive and corrosive capability of gastric juices in humans was first extensively described in 1833 by Beaumont1 as a result of experiments performed on Alexis St. Martin. That reflux of these juices into the esophagus could cause symptoms and result in tissue injury was suspected as early as 1839 by Albers, who, as reported by Tileston,2 described a peptic ulcer of the esophagus that was similar to a peptic ulcer of the stomach. Periodic reports of peptic esophageal ulcer subsequently appeared, although the existence of this phenomenon was still in doubt in the second half of the 19th century. Quincke's3 report of three well-documented cases of peptic esophageal ulceration in 1879 put all doubt to rest. Tileston2 summarized reports of 40 cases of...

Display 72 Lactamase Inhibitor Combinations

There are many traditional uses of the herb, such as an antiseptic for the skin, mouthwash for canker sores, wash for inflamed or infected eyes, and the treatment of sinus infections and digestive problems, such as peptic ulcers and gastritis. Some evidence supports the use of goldenseal to treat diarrhea caused by bacteria or intestinal parasites, such as Giardia. The herb is contraindicated during pregnancy and in patients with hypertension. Adverse reactions are rare when the herb is used as directed. However, this herb should not be taken for more than a few days to a week. Because of widespread use, destruction of its natural habitats, and renewed interest in its use as an herbal remedy, goldenseal was classified as an endangered plant in 1997 by the US government.

Herbal Alert Willow Bark

Willow bark has a long history of use as an analgesic. Willows are small trees or shrubs that grow in moist places, often along riverbanks in temperate or cold climates. When used as a medicinal herb, willow bark is collected in early spring from young branches. In addition to its use as a pain reliever, various species of willow bark and leaf have been used to lower fever and as an anti-inflammatory. The salicylates were isolated from willow bark and identified as the most like source of the bark's anti-inflammatory effects. The chemical structure was replicated in the lab and mass produced as synthetic salicylic acid. Years later, a modified version (acetylsalicylic acid) was first sold as aspirin. Aspirin became the most widely used pain reliever, fever reducer, and anti-inflammatory agent, leaving willow bark to be cast aside. The synthetic anti-inflammatory drugs work quickly and have a higher potency than willow bark. Willow bark takes longer to work and may need fairly high...

Contraindications Precautions And Interactions

These drugs are contraindicated in patients with an allergy to the p blockers, in patients with sinus bradycardia, second- or third-degree heart block, heart failure, and those with asthma, emphysema, or hypotension. The drugs are used cautiously in patients with diabetes, thyrotoxicosis, and peptic ulcer.

Preadministration Assessment

Before administering a cholinergic blocking drug to a patient for the first time, the nurse obtains a thorough health history as well as a history of the signs and symptoms of the current disorder. The focus of the initial physical assessment depends on the reason for administering the drug. In most instances, the nurse obtains the blood pressure, pulse, and respiratory rate. The nurse also may include additional assessments, such as checking the stool of the patient who has a peptic ulcer for color and signs of occult blood, determining visual acuity in the patient with glaucoma, or looking for signs of dehydration and weighing the patient if prolonged diarrhea is one of the patient's symptoms.

Ongoing Assessment

Observes for adverse drug reactions, and evaluates the symptoms and complaints related to the patient's diagnosis. For example, the nurse questions the patient with a peptic ulcer regarding current symptoms, then makes a comparison of these symptoms to the symptoms present before the start of therapy. The nurse reports any increase in the severity of symptoms to the primary health care provider immediately.

Critical Thinking Exercises

Anthony is prescribed a cholinergic blocking drug for the treatment of peptic ulcer. In planning patient teaching for Mr. Anthony before dismissal from the hospital, determine what information must be included to prevent complications of therapy. 3. Mr. Salinas is prescribed a cholinergic blocking drug for a gastric ulcer. You note in the admission interview that he states that he has a history of enlarged prostate. Discuss how Mr. Salinas' history of enlarged prostate relates to the drug therapy for a gastric ulcer. 4. Develop a teaching plan for Ms. Likens, age 54 years, who will be taking glycopyrrolate (Robinul) for a peptic ulcer. Ms. Likens is alert, well oriented, and teaches school at a local high school.

Laurie Haas and Luis Marsano

Patients with infections of the gastrointestinal (GI) tract may present with a range of complaints from vague symptoms such as malaise and anorexia to more serious manifestations such as severe diarrhea and sepsis. Although many GI infections require antibiotic therapy, others cause self-limited disease and only supportive care is needed. In the last decade, the recognition of the clinical importance of Helicobacter pylori and its cause and effect on peptic ulcer disease has changed what was once thought to be a disorder of excessive acid production to an infectious disease. The rising incidence of hepatitis C virus and progression to chronic active hepatitis and cirrhosis has also placed a tremendous burden on the health care system to find more effective and tolerable therapies for this disease. The emergence of resistance to antibiotics used to treat many of these infections, especially Helicobacter pylori infection and infectious diar-rheal syndromes, poses new challenges for...

Contraindications

Absolute contraindications include major hypersensi-tivity (anesthetic solutions and steroids), local infection at the site of proposed injection, systemic infection, coagulopathy, and contraindication to steroid therapy (active bleeding from gastritis or peptic ulcer disease, resistant diabetes mellitus, severe congestive heart failure, and severe hypertension). Relative contraindications include an allergy to iodinated contrast agents (procedure can be performed without contrast).

Representative other applications

Colonized individuals are asymptomatic, a subpopulation of 10-20 develops peptic ulcers that may in turn evolve into adenocarcinoma 30-90 of gastric cancers (a major health problem worldwide) are tied to this microorganism 144 . There are significant clinical and economic aspects of screening for, and diagnosis of, this infection 145 .

Microbial iron acquisition

Helicobacter pylori is known to be an etiologic agent of gastritis and peptic ulcer disease in humans. Human LF supported full growth of the II pylori in media lacking other iron sources, but neither human TF, bovine LF, nor hen ovoTF served as a source for iron (Husson et al., 1993). Since hLF is found in significant amounts in human stomach resections with superficial or atrophic gastritis, the iron acquisition system of H. pylori by the hLF receptor system may play a major role in the virulence of H. pylori infection. Most H. pylori strains also seem to produce extracellular siderophores (Illingworth et al., 1993).

Discovery And Taxonomy

Although diseases such as peptic ulcer disease and gastric cancer have been recognized for centuries, an infectious cause was not actively pursued until the latter part of the 20th century. Prior to 1982, peptic ulcer disease was attributed to excessive acid or stress, while gastric cancer was linked to a number of dietary factors suggested by extensive epidemiologic surveys. Both were known to be associated with chronic inflammation (gastritis) of the stomach, but this association remained unexplained. Nevertheless, the existence of gastric bacteria and a possible association with ulcer disease had been reported by investigators dating as far back as the 19 th century. For example, in 1875, Bottcher and Letulle were able to demonstrate the presence of bacteria within the floor and margins of ulcers (1), and Jaworski in 1889 described the presence of spiral organisms in the sediment of gastric washings. In 1924, Luck detected the presence of urease activity within the gastric mucosa....

Fibric Acid Derivatives

The fibric acid derivatives are contraindicated in patients with hypersensitivity to the drugs and those with significant hepatic or renal dysfunction or primary biliary cirrhosis because these drugs may increase the already elevated cholesterol. The drugs are used cautiously during pregnancy (Pregnancy Category C) and lactation and in patients with peptic ulcer disease or diabetes. Although it rarely occurs, when the fibric acid derivatives, particularly gemfibrozil, are administered with the HMG-CoA reductase inhibitors, there is an increased risk for rhabdomyolysis (see Nursing Alert). When clofibrate, fenofibrate, or gemfibrozil is administered with the anticoagulants, there is an increased risk for bleeding.

Factors Contributing To Malignancy

Although the prevalence of strains with the pathogenicity island varies across populations (149,150), it is not clear that this variation translates into differences in disease incidence. Moreover, variation in H. pylori strain type cannot explain the differences between population rates of peptic ulcer disease and gastric cancer, as CagA-positive strains appear to increase risk for both of these conditions (151). Fig. 3. Model of progression of H. pylori-associated clinical conditions. H. pylori causes gastritis, either confined to the antrum or corpus-wide this distribution is probably associated with age at infection and or host susceptibility. Antrum-based infection causes increased acid production and increased risk of duodenal ulcer (DU). Corpus infection leads to decreased acid levels via loss of parietal cells through atrophy. In a subset of persons with chronic atrophic gastritis, this low acid environment predisposes to the development of gastric ulcer and or cancer. Of...

Herbal Alert Chamomile

Chamomile has several uses in traditional herbal therapy, such as a mild sedative, digestive upsets, menstrual cramps, and stomach ulcers. It has been used topically for skin irritation and inflammation. Chamomile is on the US Food and Drug Administration list of herbs generally recognized as safe (GRAS). It is one of the most popular teas in Europe. When used as a tea, it appears to produce an antispasmodic effect on the smooth muscle of the gastrointestinal (GI) tract and to protect against the development of stomach ulcers. Although the herb is generally safe and nontoxic, the tea is prepared from the pollen-filled flower heads and has resulted in mild symptoms of contact dermatitis to severe anaphylactic reactions in individuals hypersensitive to ragweed, asters, and chrysanthemums.

Promoting an Optimal Response to Therapy

Tablet form, the nurse informs the primary health care provider. A flavored antacid may be ordered if the taste is a problem. A liquid form may be ordered if the patient has a problem chewing a tablet. The primary health care provider may order that the antacid be left at the patient's bedside for self-administration. The nurse makes certain an adequate supply of water and cups for measuring the dose are available. The antacid may be administered hourly for the first 2 weeks when used to treat acute peptic ulcer. After the first 2 weeks, the drug is administered 1 to 2 hours after meals and at bedtime.

Antibiotics In Medical Settings For Diseases Not Traditionally Viewed As Infections The Example Of Cardiovascular

An exciting new area of research is the possible etiologic role of infections in the development of illnesses not traditionally viewed as infectious. The documentation of H. pylori as the cause of peptic ulcer disease has led to the use of antibiotics in many patients. The recognition that HHV-8 is the cause of Kaposi's sarcoma suggests that cancers may require treatment with antiviral agents. Currently, infections have been hypothesized to play a role in the development of diseases ranging from neuropsychiatric problems to multiple sclerosis. As more and more of these diseases are found to be due to infection, more and more people will receive courses of antimicrobial therapies, in some cases for prolonged periods of time. The impact of these new therapeutic choices on the development of antibiotic resistance will become clearer over the next few years.

Chamomile and Matricaria

Roman chamomile is usually taken as an aqueous infusion (chamomile tea) to aid digestion, curb flatulence, etc, but extracts also feature in mouthwashes, shampoos, and many pharmaceutical preparations. It has mild antiseptic and anti-inflammatory properties. The flowerheads yield 0.4-1.5 of volatile oil, which contains over 75 of aliphatic esters of angelic, tiglic, isovaleric, and isobutyric acids (Figure 5.29), products of isoleucine, leucine, and valine metabolism (see pages 100, 295, 306), with small amounts of monoterpenes and sesquiterpenes. Matricaria is also used as a digestive aid, but is mainly employed for its anti-inflammatory and spasmolytic properties. Extracts or the volatile oil find use in creams and ointments to treat inflammatory skin conditions, and as an antibacterial and antifungal agent. Taken internally, matricaria may help in the control of gastric ulcers. The flowers yield 0.5-1.5 volatile oil containing the sesquiterpenes a-bisabolol (10-25 ), bisabolol...

Test Your Knowledge ofTerms and Facts

Explain the function of bicarbonate in pancreatic juice. How may peptic ulcers in the duodenum be produced 4. Describe the mechanisms that are believed to protect the gastric mucosa from self-digestion. What factors might be responsible for the development of a peptic ulcer in the stomach

Gastrointestinal Tract Infection

Inguinal Colostomy

An ulcer is a lesion of the skin or a mucous membrane marked by inflammation and tissue damage. Ulcers caused by the damaging action of gastric, or peptic, juices on the lining of the GI tract are termed peptic ulcers. Most peptic ulcers appear in the first portion of the duodenum. The origins of such ulcers are not completely known, although infection with a bacterium, Helicobacter pylori, has been identified as a major cause. Heredity and stress may be factors as well as chronic inflammation and exposure to damaging drugs, such as

Atrophic Gastritis and Gastric Carcinoma

Epidemiological and experimental data suggest that H. pylori does not cause gastric adenocarci-noma directly but, instead, predisposes to its development in a stepwise series of events from gastritis, atrophic gastritis, intestinal metaplasia, and epithelial dysplasia. When chronic atrophic gastritis becomes severe and extensive, the resulting hypochlorhydria favors bacterial overgrowth with the appearance of nitrites and N-nitroso compounds in the gastric lumen. Such compounds may induce epithelial dysplasia because of their mutagenic and carcinogenic properties (40). Interestingly, duodenal ulcer disease protects against, whereas gastric ulcer increases the risk of, subsequent gastric carcinoma (38,41). This disparity suggests that normal or high acid output associated with duodenal ulcer disease represents a defense factor against a malignant development and or that the low acid output associated with gastric ulcer favors oncogenesis.

Gastric Secretion Is Under Neural and Hormonal Control

Histamine Acid Secretion

Gastric acid secretion is mediated through neural and hormonal pathways. Vagus nerve stimulation is the neural effector,- histamine and gastrin are the hormonal effectors (Fig. 27.8). Parietal cells possess special histamine receptors, H2 receptors, whose stimulation results in increased acid secretion. Special endocrine cells of the stomach, known as enterochromaffin-like (ECL) cells are believed to be the source of this histamine, but the mechanisms that stimulate them to release histamine are poorly understood. The importance of histamine as an effector of gastric acid secretion has been indirectly demonstrated by the effectiveness of cimetidine, an H2 blocker, in reducing acid secretion. H2 blockers are commonly used for the treatment of peptic ulcer disease or gastroesophageal reflux disease.

Dyspepsia indigestion

Indigestion' is a common complaint, it is essential that the patient explains in detail what is meant by this vague term. Indigestion might describe nausea, heartburn, epigastric discomfort, abdominal pain, belching or a feeling of postprandial bloating. It may even be used to describe angina pectoris. Peptic ulcers usually produce characteristic symptoms, as shown in Table 5.7. Differentiation between oesophageal, gastric or duodenal ulcers on Ihe basis of symptoms alone is often unreliable.

Stress and the Adrenal Gland

List Glands And Its Secretions

In 1936, a Canadian physiologist, Hans Selye, discovered that injections of a cattle ovary extract into rats (1) stimulated growth of the adrenal cortex (2) caused atrophy of the lym-phoid tissue of the spleen, lymph nodes, and thymus and (3) produced bleeding peptic ulcers. At first he attributed these effects to the action of a specific hormone in the extract. However subsequent experiments revealed that injections of a variety of substances including foreign chemicals such as formaldehyde could produce the same effects. Indeed, the same pattern occurred when Selye subjected rats to cold environments or when he dropped them into water and made them swim until they were exhausted.

Examples of Prostaglandin Actions

The stomach and intestines produce prostaglandins, which are believed to inhibit gastric secretions and influence intestinal motility and fluid absorption. Since prostaglandins inhibit gastric secretion, drugs that suppress prostaglandin production may make a patient more susceptible to peptic ulcers.

Sphincters Prevent the Reflux of Luminal Contents

The lower esophageal sphincter prevents the reflux of gastric acid into the esophagus. Incompetence results in chronic exposure of the esophageal mucosa to acid, which can lead to heartburn and dysplastic changes that may become cancerous. The gastroduodenal sphincter or pyloric sphincter prevents the excessive reflux of duodenal contents into the stomach. Incompetence of this sphincter can result in the reflux of bile acids from the duodenum. Bile acids are damaging to the protective barrier in the gastric mucosa,- prolonged exposure can lead to gastric ulcers.

Animal Models For Helicobacterinduced Gastric Cancer

Although administration of V-nitro chemicals with and without salt in animals addressed the possible roles and mechanisms of promoters and nitrosamine induced gastric cancer, it now is clear that H. pylori is an important factor in gastric tumorigen-esis. Furthermore, despite the presence of high nitrites in drinking waters and possible mutagenicity of nitrosated foods, the inconsistency of epidemiologic data suggests that high levels of dietary nitrites nitrates and high-salt diets alone are not sufficient to produce overt gastric cancer in humans. Therefore animal models are being developed to study the role of Helicobacter species in gastric cancer, particularly in combination with other agents. During the last decade, several animal models have been described for Helicobacter-induced gastric disease. Of the animal models recently reviewed (121), gastric adenocarcinoma occurred only with H. mustelae (122). Recently, the ger-bil has been shown to have particular relevant features...

Herbal Sleeping Potion Was Mixed Into Tea And Taken At Bedtime

P.L., who has a 4-year history of heart disease, was brought to the emergency room by ambulance with chest pain that radiated down her arm, dyspnea, and syncope. Her routine meds included Lanoxin to slow and strengthen her heart beat, Inderal to support her heart rhythm, Lipitor to decrease her cholesterol, Catapres to lower her hypertension, nitroglycerin prn for chest pain, Hydro-DIURIL to eliminate fluid and decrease the workload of her heart, Diabinese for her diabetes, and Coumadin to prevent blood clots. She also took Tagamet for her stomach ulcer and several OTC preparations, including an herbal sleeping potion that she mixed in tea, and Metamucil mixed in orange juice every morning for her bowels. Shortly after admission, P.L.'s heart rate deteriorated into full cardiac arrest. Immediate resuscitation was instituted with cardiopulmonary resuscitation (CPR), defibrillation, and a bolus of IV epinephrine. Between shocks she was given a bolus of lidocaine and a bolus of diltiazem...

Haemophilus ducreyi and Haemophilus aegyptius

H. ducreyi are short, Gram-negative, nonmotile rods that are difficult to culture and require special mediums. This bacterium causes ulcus molle (soft chancre) a tropical venereal disease seen rarely in central Europe. The infection locus presents as a painful, readily bleeding ulcer occurring mainly in the genital area. Regional lymph nodes are quite swollen. Identification of the pathogen by means of microscopy and culturing are needed to confirm the diagnosis. Therapeutic alternatives include sulfonamides, streptomycin, and tetracyclines.

Complications of Barretts Esophagus

Age, making it an important concern in the elderly. Barrett's esophagus is an indication for esophagectomy in two classes of individuals. First, in rare circumstances a Barrett's ulcer can develop, which burrows deeply like a gastric ulcer instead of spreading superficially like ulcerations in the squamous esophageal mucosa. Although such ulcers can be controlled with intensive medical therapy, they sometimes extend transmurally and invade other structures, creating a life-threatening situation. In the presence of a deep chronic Barrett's ulcer, esophagectomy should be strongly considered.

Patterns of presentation

A sudden onset of severe abdominal pain which progresses rapidly, becomes generalised in site and constant in nature, in a' previously asymptomatic patient, suggests either perforation of a hollow viscus, a ruptured aortic aneurysm or a mesenteric arterial occlusion. Prior symptoms may help the differential diagnosis preceding constipation suggests colonic carcinoma or diverticular disease as the catisc of the perforation, and preceding dyspepsia suggests a perforated peptic ulcer. Coexisting peripheral vascular disease, hypertension, cardiac failure or atrial fibrillation suggest a vascular disorder, e.g. aortic aneurysm, mesenteric ischaemia. The development of peripheral circulatory failure (shock) following the onset of the pain, strongly suggests intra-abdominal bleeding, e.g. ruptured aortic aneurysm or ectopic pregnancy. The rapid onset of abdominal pain may also occur if an organ twists -

Control Measures

The development of a safe and effective vaccine for the prevention of H. pylori infection should lower the incidence of both peptic ulcer disease and gastric cancer and may lessen the emergence of drug-resistant H. pylori strains. Vaccine development in laboratory animals has been promising. Oral immunization with H. pylori urease protects mice against H. felis infection (119). Also, an H. pylori mouse model has been developed, and oral immunization with purified H. pylori antigens protects mice against bacterial infection (120). Interestingly, chronic H. pylori infection in mice can be successfully eradicated by intragastric vaccination with H. pylori antigens such as recombinant VacA or CagA, administered together with a genetically detoxified mutant of the heat-labile exotoxin of E. coli (121). Moreover, such therapeutic vaccination confers efficacious protection against reinfection (121). Regrettably, no vaccine is as yet available for use in humans. However, Kreiss et al. (122)...

Exercise Can Modify the Rate of Gastric Emptying and Intestinal Absorption

Dynamic exercise must be strenuous (demanding more than 70 of the maximal oxygen uptake) to slow gastric emptying of liquids. Little is known of the neural, hormonal, or intrinsic smooth muscle basis for this effect. Although gastric acid secretion is unchanged by acute exercise of any intensity, nothing is known about the effects of exercise on other factors relevant to the development or healing of peptic ulcers. There is some evidence that strenuous postprandial dynamic exercise provokes gastroe-sophageal reflux by altering esophageal motility.

Gerontologic Alert

EDUCATING THE PATIENT WITH A PEPTIC ULCER. The nurse gives the patient with a peptic ulcer a full explanation of the treatment regimen, which may include drugs and a special diet. The patient is instructed to take the drug exactly as prescribed by the primary health care provider (eg, 30 minutes before meals or between meals) to obtain the desired results. The nurse discusses the importance of diet in the treatment of peptic ulcer and gives a full explanation of the special diet (when ordered).

Acquired Iron Deficiency

Organs responsible for development of iron-deficiency anaemia are the uterus (increased menstrual blood loss, pregnancy), the oesophagus (varicose veins in patients with liver cirrhosis), the stomach and bulbus duodeni (hiatus hernia, aspirin and detrimental effects of other non-steroidal antiinflammatory drugs, peptic ulcer, carcinoma, partial gastrectomy), the small intestine (hookworm, coeliac disease, diverticulosis, morbus Crohn, angiodysplasia), the colon and rectum (carcinoma, diverticulosis, angiodysplasia, varices, colitis) and, rarely, the kidney and lung. Increased demands for iron, not met by adequate iron intake, occur in premature infants, during any period associated with increased growth, and during pregnancy. Poor diet is also a cause of iron deficiency in some socioeconomic groups in developed countries. Female blood donors in particular may develop iron deficiency. Self-inflicted blood loss is a diagnosis that should be considered if no cause can be found for severe...

Medications

Antiinflammatory medications are useful for arthritic problems involving the hip joint. Nonsteroidal antiinflammatory drugs such as ibuprofen 600 mg to 800 mg three times daily can be helpful. These medications are contraindicated in patients taking anticoagulants or who have peptic ulcer or renal disease. Cox-2 specific antiinflammatory agents may offer relief to patients who are currently unable to take traditional NSAIDs.

Naproxen

Naproxen is contraindicated in patients who are allergic to the drug or other NSAIDs and during pregnancy (Category B) and lactation. The drug is used cautiously in patients with asthma, hypertension, cardiac problems, peptic ulcer disease, and impaired liver or kidney function. Like ibuprofen, naproxen increases the risk of lithium toxicity when the drug is administered with naproxen. When naproxen is administered with the anticoagulants there is an increased risk for bleeding. When naproxen is administered with the antihyperten-sives, there is a decrease in the antihypertensive effect. Coadministration of naproxen with the diuretics decreases the diuretic effect.

Celecoxib

The drug is used cautiously in patients with a history of peptic ulcer, individuals older than 60 years, and those taking an anticoagulant or steroids. In rare instances, serious stomach problems such as bleeding can occur without warning. When celecoxib is given with the anticoagulants, there is an increased risk for bleeding.

Rofecoxib

Rofecoxib is contraindicated in patients who are allergic to the drug, any of the NSAIDs, or the sulfonamides. The drug is not used during pregnancy (Category C) or lactation. Rofecoxib is used cautiously in patients with impaired renal or hepatic function, in those with a history of gastrointestinal bleeding or peptic ulcer disease, and in patients with congestive heart failure, asthma, or hypertension. Interactions with rofecoxib are similar to those with the other NSAIDs, such as an increased risk of bleeding when taken with anticoagulants and possible risk of lithium toxicity when taken concurrently with lithium.

BFollowup

Although their dominant action relates to the ability to inhibit the cyclooxygenase enzyme and thus pro-inflammatory prostaglandins, NSAIDs also inhibit lipoxygenase and lysosomal enzyme release, antagonize kinins, and induce apoptosis. Cyclooxygenase-1 (COX-1) is present in many tissues and is responsible for the production of prostaglandins in the gastric mucosa, endothelium, platelets, and kidneys. COX-1 inhibition by NSAIDs is linked to known adverse effects, such as gastric ulceration and renal toxicity. Cyclooxygenase-2 (COX-2) is an inducible, pro-inflammatory enzyme. Although different NSAIDs vary in the degree to which they inhibit both enzymes, in many cases, both COX-1 and COX-2 are inhibited at the high doses used for clinical purposes. Two new COX-2-specific inhibitors are now in widespread use (Celebrex and Vioxx) although similar in effectiveness to other NSAIDs, they appear to cause significantly less gastrointestinal toxicity. c. Therapeutic...

Liquorice

Glycyrrhizin is reported to be 50-150 times as sweet as sucrose, and liquorice has thus long been used in pharmacy to mask the taste of bitter drugs. Its surfactant properties have also been exploited in various formulations, as have its demulcent and mild expectorant properties. More recently, some corticosteroid-like activity has been recognized, liquorice extracts displaying mild anti-inflammatory and mineralocorticoid activities. These have been exploited in the treatment of rheumatoid arthritis, Addison's disease (chronic adrenocortical insufficiency), and various inflammatory conditions. Glycyrrhetic acid has been implicated in these activities, and has been found to inhibit enzymes that catalyse the conversion of prostaglandins and glucocorticoids into inactive metabolites. This results in increased levels of prostaglandins, e.g. PGE2 and PGF2a (see page 54), and of hydrocortisone (see page 268). Perhaps the most important current application is to give systematic relief from...

Mesenteric Ischemia

Acute Mesenteric Ischemia

Chronic mesenteric ischemia generally occurs when there is insufficient blood supply to the intestine during periods of high metabolic demand, such as following a meal. It is most commonly caused by severe stenosis or occlusion of at least two of the three main splanchnic arteries. The clinical syndrome of mesenteric ischemia is rare. Symptoms may include abdominal pain, weight loss and food aversion 3,18-19 .Atherosclerosis of the splanchnic arteries is considered to be the main pathophysiologic mechanism for chronic mesenteric ischemia 1,5 . However, the diagnosis of mesenteric ischemia is frequently perplexing in clinical practice. Reflecting the risks associated with arterial catheterization, the clinical diagnosis of mesenteric ischemia has been mostly one of exclusion. The median time-delay between clinical presentation and diagnosis is 18 months for patients with new symptoms and one month for patients with recurrent symptoms. Symptoms of mesenteric ischemia may overlap with...

Neurologic disease

Other side effects of corticosteroids include increased intraocular pressure, which may precipitate glaucoma, and the occurrence of posterior subcapsular cataracts. Although dyspepsia may accompany the use of steroids, it usually responds to antacids or histamine 2 blockers and administration of medication with meals. Enhancement of peptic ulcer disease probably does not occur. Menstrual irregularities, night sweats, and pancreatitis have been associated with corticosteroid therapy. Pseudotumor cerebri, associated with rapid steroid dosage reduction, is a rare complication.

Endocrine disease

Peptic ulcer disease, a common condition in rheumatic disease patients, may be exacerbated during the perioperative period and is particularly problematic in the arthroplasty patient who is to be placed on prophylactic anticoagulant therapy after surgery. Therefore, patients with a history of peptic ulcer disease, gastrointestinal bleeding, or active symptoms of dyspepsia should receive prophylactic histamine 2 blocker therapy throughout the postoperative period. If clinical suspicion is strong that an active peptic process is ongoing, the surgery should be canceled, a workup performed, and treatment instituted before the surgery is undertaken. In patients at risk for the development of gastrointestinal bleeding after surgery, serial stool guaiac tests are a good approach to surveillance.

Mortality Rates

Three reviews that summarized results from studies conducted between 1942 and 1996 found the mortality rate in patients with schizophrenia to be between 1.5 and 2 times that expected. Allebeck (1989) reviewed nine studies published between 1942 and 1985 in which patients had been followed at least 5 years and he found mortality of about twice the expected rate. He noted difficulty in ascertaining whether rates had changed because diagnostic and study criteria had varied over time. Brown (1997) searched for studies published between 1986 and 1996 with schizophrenic patient populations of at least 100 individuals recruited after 1952 that included observed and expected death rates and had follow-up periods of at least 2 years, with losses to follow-up of less than 15 . He found an aggregate SMR of 151 (SMRx 100, 95 CI 148-154). The SMR for suicide was elevated at 838 (SMRx 100, 95 CI 784-894), as were the SMR for accidents (216, 95 CI 196-236) and the SMR for natural causes of death...

Epidemiology

Tic gastric irradiation for peptic ulcer disease (31), and in association with Alport's syndrome (32). From 1985 to 1990, five cases of leiomyosarcoma associated with HIV-1 infection, all of which occurred in children, were reported (33-35), including three cases by Chadwick et al. (35), who suggested that this association indicated a direct or indirect role for HIV-1 infection in the development of leiomyosarcoma. Eleven additional cases of leiomyomas and leiomyosarcomas in HIV-1-infected persons were subsequently reported by others from 1991 through 1994 (36-44), including nine children (36,37,39-41,43,44), one adolescent (38), and one adult (42). (One case in the series by Chadwick et al. 35 was also in a separate report 45,46 the imaging studies of the case reported by Sabatino et al. 36 were reported by Balsam and Segal 47 .)

Gastric Infections

The discovery of Helicobacter pylori has dramatically transformed the approach to diagnosis and treatment of peptic ulcer disease. It is now known that H. pylori accounts for 70 of duodenal ulcers, 60-90 of gastric ulcers, and is also a cause of atrophic gastritis. H. pylori is also found in nearly 100 of individuals with chronic active gastritis. In addition, H. pylori has been classified as a type I carcinogen by the World Health Organization and has a strong association with gastric cancer and lymphoma. H. pylori is a helical Gram-negative rod that produces a variety of enzymes that help the organism adapt to its acidic environment. It is found only in gastric epithelium however, it can be found in other areas of the gastrointestinal tract secondary to gastric metaplasia (11). H. pylori is found worldwide, with a higher incidence in underdeveloped and third world countries. It is reported that two-thirds of the world's population is infected with H. pylori and random testing of...