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Summary The prevalence of duodenal ulceration in India, Africa, China and other developing countries is high in some regions and low in others, despite a high prevalence of Helicobacter pylori infection throughout the areas. This variation is related to the staple diet of the regions involved. In regions where, because of the climate, the staple food is milled white rice, wheat or maize, or cassava, yams,sweet potato and green bananas the prevalence of duodenal ulcer is higher than in regions where the staple diet is based on unrefined wheat or maize, soya, certain millets or pulses. These differences have been reproduced in animal peptic ulcer models. Using these models it has been shown that the protective factor against ulceration lies in the lipid fraction present in staple foods from the low prevalence areas. The lipid fraction not only gave protection in the experimental models against ulceration but also promoted healing. The pulse Dolichos biflorus (horse gram) gave the greatest yield of the lipid and this was used for further investigations. It was found that the ulceroprotective activity of the lipid lay in its phospholipid and sterols fractions. The presence or absence of protective lipid in the diet would account for the regional differences in duodenal ulcer prevalence.

Background : Helicobacter pylori is thought to be a cause of duodenal ulceration, but there is some evidence that it is found less often in early than in later disease. Aim : To assess the presence of H. pylori in patients undergoing endoscopy for dyspepsia, with respect to their duration of symptoms. Design : Retrospective case note review. Methods : Patients were categorized as having a history greater or less than 6 months, and as H. pylori ‐positive or ‐negative, using biopsy rapid urease, culture and PCR tests. Results : Thirty‐two duodenal ulcer patients with a history >6 months were all H. pylori ‐positive according to the PCR test; the five with a shorter history were H. pylori ‐negative. No patient H. pylori ‐negative by PCR was positive by the other tests. Discussion : H. pylori was (at least) less commonly present before 6 months. It is possible that H. pylori , although nearly always present after 6 months, is not present at the onset of the disease. Confirmation of this finding would imply that infection with the organism is not the cause of duodenal ulceration, but a factor producing recurrence and chronicity.

A previous study suggested that Helicobacter pylori strains possessing dupA are positively associated with duodenal ulceration and negatively associated with gastric adenocarcinoma. We determined the prevalence of dupA in H. pylori strains recovered from 4 independent populations and found a significant association with gastric cancer but not with duodenal ulceration.

To assess the effect of 4 weeks' therapy with ranitidine 150 mg twice daily on the healing of symptomatic NSAID-associated gastric and duodenal ulcers, 149 arthritic patients were randomly allocated to one of three treatment groups: ranitidine with NSAID continued, ranitidine with NSAID discontinued, and placebo with NSAID discontinued. The healing frequency in patients with gastric ulceration was 67, 68 and 47%, and in those with duodenal ulceration 61, 81 and 42%, respectively. Only the difference between the duodenal ulcer healing rates for ranitidine with NSAID discontinued and placebo was statistically significant (P = 0.02). Healing rates were uninfluenced by gender, age, smoking habits, alcohol consumption, ulcer frequency or size, arthritic disease, or participating country.

A retrospective study was performed of 163 patients aged 65 years and over with a diagnosis of duodenal ulceration admitted to one Health District over a period of six years. Eighty per cent of the patients were admitted with acute complications, 50% bled and 30% were perforated. A large proportion of these patients were currently taking anti-inflammatory agents. Patients managed surgically for their complications had a high mortality rate but this was even higher for those managed conservatively. Giant ulcers were found to occur frequently in this age group which had a tendency to severe bleeding. It is concluded that early diagnosis and prompt surgical intervention is essential in the management of complications associated with duodenal ulceration in the elderly.

A total of 153 patients (124 male and 29 female) with uncomplicated chronic duodenal ulceration were studied in a prospective, randomized trial of proximal gastric vagotomy (PGV) and truncal vagotomy and pyloroplasty (TVP), conducted in four Manchester hospitals. Of these, 137 patients have now been followed up for 2·5 to 5·5 (mean 4·1) yr. There have been 15 (21 per cent) recurrent ulcers following PGV compared with 5 (7·5 per cent) after TVP (P < 0·05). A satisfactory functional result was obtained in 82 per cent of patients after TVP compared with 73 per cent following PGV and there was little difference between the groups with regard to the incidence of dumping, heartburn and vomiting. There was significantly more diarrhoea following TVP (13 per cent) compared to PGV (1·4 per cent) but this represented only a minor clinical problem.

Gastric secretory studies are subject to considerable error owing to incomplete collections and to contamination by reflux of alkaline duodenal contents. Corrections for these sources of error have been defined, and they have been extensively applied in a research setting. In order to assess their utility in the performance of routine gastric secretory studies? the value of such corrections was assessed in 56 studies in patients with duodenal ulceration (10), previous surgical vagotomy (8), reflux oesophagitis (30) and primary oesophageal motility disorders (8). The effect of such corrections was small, and there were close correlations between uncorrected and corrected acid outputs in all four groups. The status of the vagal efferent gastric fibres was assessed by comparing the acid output after insulin hypoglycaemia with the maximal acid output after pentagastrin (insulin: pentagastrin ratio). The application of the corrections did not alter the conclusion regarding the assessment of vagal status in 55 of the 56 studies performed. It is concluded that such corrections are not necessary in the routine performance of gastric secretory studies.

The results of a randomized, prospective clinicol trial of highly selective vagotomy (HSV) versus truncal vagotomy and pyloroplasty (TVP) in 126 male patients undergoing elective surgery for chronic duodenal ulceration are presented. The operations were performed by surgeons of all grades of experience. At a mean follow-up time of just over 3 years a satisfactory result was obtained in 93 per cent of patients following HSV and 78 per cent of patients following TVP, the difference being probably statistically significant (P

Summary A case of the Zollinger-Ellison syndrome, presented with watery diarrhoea, malabsorption and multiple duodenal ulcers. Resection of a gastrinoma from the head of the pancreas was ineffective. Cimetidine, administered for more than 30 months produced an immediate and sustained relief of symptoms with a gain in weight of 19 kg and improvement of the biochemical features of malabsorption. Gastric acid secretion has been markedly inhibited and duodenal ulceration healed.

Maximal gastric secretion was studied in 34 control subjects and 29 patients with duodenal ulcer using the histamine-infusion test with the addition of an inert marker, phenol red, to correct for pyloric losses of gastric secretion. In the control group, statistically significant correlations were found between maximal gastric secretion and almost all the indices of body stature. Correction for pyloric loss improved all the correlations and raised those correlation coefficients which were not significant to levels of confidence of 95 percent or more. The validity of calculation of lean body mass from height and weight was checked by the estimation of total body potassium in 26 subjects. When lean body mass was taken into account it was confirmed that maximal gastric secretion decreased with age, but the sex difference in maximal gastric secretion was no longer statistically significant. In the duodenal ulcer group, maximal gastric secretion was also significantly correlated with stature, though not with age. It is, therefore, proposed that stature should be taken into account when defining hypersecretion. As expected, patients with duodenal ulcer produced as a group significantly higher levels of maximal gastric secretion than did control subjects, but the effect appeared to be due to a minority of patients with hypersecretion. Patients with a history of less than 4 years secreted proportionately less gastric juice than those with a longer history. This finding raises the possibility that gastric hypersecretion is a result of duodenal ulceration rather than a cause.

Nine cases of perforation whilst patients received cimetidine therapy were identified and followed prospectively. There was a high correlation with the other major complications of duodenal ulceration: pyloric stenosis and haemorrhage. Initially, three of the nine patients had simple suture of the perforation, but eventually all required truncal vagotomy and a drainage procedure. The follow-up ranges from 6 months to 2.5 years and the results in the surviving patients are good. The pre-operative identification of this group, being established medical failures with the high probability of requiring necessary definitive surgery, will aid the surgical management of this condition.

A retrospective survey of patients having truncal vagotomy for duodenal ulceration has been carried out. In this series 41 cases of oesophageal perforation occurred; 29 were recognized at the time of operation, 6 were diagnosed postoperatively, and in the remaining 6 the time of diagnosis was not specified. Two of the 29 patients in whom the oesophageal perforation was recognized at the time of operation died, as did 2 of the 6 cases diagnosed postoperatively. An increase of mortality and morbidity occurred in those diagnosed postoperatively. The importance of confirming oesophageal integrity at the conclusion of vagotomy is stressed.