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Portoenteric fistula is a rare cause of massive upper gastrointestinal bleeding. Most cases can be treated with radiointervention or surgery, but portoenteric fistula is associated with a high mortality. We reported a case of intermittent massive upper gastrointestinal bleeding in a 33-year-old man with cholangiocarcinoma who underwent surgical resection followed by chemoradiation. A portoduodenal fistula due to chronic duodenal ulceration was identified. The bleeding was successfully controlled by endoscopic ultrasound-guided coil placement through the duodenal bulb using the anchoring technique. Follow-up endoscopy and computed tomography scan showed multiple coil placements between a part of the portal vein and the duodenal bulb without any evidence of portal vein thrombosis. There were no complications, and bleeding did not recur during the 8-month follow-up period.

Deployment of bare metal duodenal stents for individuals with gastric outlet obstructions (GOOs) is a well-characterized measure to improve the quality of life. However, these interventions are palliative in nature and are associated with known complications. We present an unfortunate case of a previously not well described, albeit not surprising, a complication of stent placement. The individual underwent duodenal stent placement due to obstructive metastatic disease and subsequently presented for gastrointestinal (GI) bleed. It was determined that an aortoduodenal fistula acutely developed and, despite heroic efforts, the patient ultimately expired.

Giant duodenal ulcers (GDUs) are full-thickness disruptions of the gastrointestinal epithelium greater than 3cm in diameter. The significant size and disease chronicity lead to deleterious outcomes and high mortality risk if ulcer progression is not halted. While still prevalent in developing countries, GDUs are increasingly rare in industrialized nations. Here, we present the case of an 82-year-old woman with perforated GDU requiring emergent surgical intervention complicated by prior duodenal surgery requiring a previously unreported triple-layered omental patch. Discussion of this technique and novel approaches to GDU repair ensue.

We present a case of a 60-year-old male diagnosed with Zollinger-Ellison syndrome (ZES) after a protracted multicentric workup for chronic diarrhea and unexplained weight loss. ZES is intrinsically difficult to diagnose due to nonspecific symptoms, which are mimicked by other more frequent pathologies, such as peptic ulcer disease secondary to Helicobacter pylori or nonsteroidal anti-inflammatory drugs. The diagnostic challenge can be further complicated by patient noncompliance, resulting in delayed management and unnecessary health care. In our case report, the patient did not adhere to the care plan preceding endoscopy and failed to maintain communication with the treating doctor. As a result, crucial information was missing, and establishing the diagnosis of ZES took six months. Delay in appropriate management also contributed to poor disease course, heavy necrotic ulceration of the duodenum and proximal jejunum that was discovered on repeat endoscopy.

A six-year-old Ragdoll with previous extrahepatic biliary tract obstruction due to cholangiohepatitis, treated with cholecystoduodenostomy, was presented for acute vomiting, hyporexia, and weight loss. Abdominal ultrasound examination revealed randomly distributed hepatic nodules and dilated biliary ducts. Gastroduodenoscopy showed a patent cholecystoduodenostoma but disclosed a perforated duodenal ulceration. Conversion to celiotomy revealed extensive liver pathology, a discrete pancreatic nodule, and a duodenal ulcer opposite to the cholecystoduodenostoma. The cat was euthanized intra-operatively and necropsy was performed. The intrahepatic biliary tract of the right liver lobes was obstructed and severely dilated, whereas bile from the left lobes drained through the cholecystoduodenostoma. Histopathologic diagnoses were a primary pancreatic tumor, positive for glucagon on immunohistochemistry, with liver metastases, chronic purulent cholecystitis, and duodenal ulceration. To the authors’ knowledge, this is the first report in which the development of pancreatic neoplasia is described in a cat with a history of biliary tract disease.

Coeliac disease (CD) is a gluten-dependent inflammatory disease of the small bowel that affects up to 1% of the global population. Herein, the presence of ulcers, erosions, or strictures in the duodenum for non-advanced cases of CD is a rarity. Case report: We present a clinical case of a 17-year-old girl, who from the age of 9, had suffered from erosive Helicobacter pylori (HP)-associated gastritis and erosive duodenitis. At 16, she was diagnosed with a duodenal ulcer, complicated by cicatricial deformity of the bulb. While an atypical course in the development of the disease had led to the initial delay in diagnosis, a serum study and an intestinal biopsy confirmed CD. Discussion: A recent study found an elevated rate of peptic ulcer disease in patients with CD. From literature searches, comorbid HP infection and CD have indeed been widely reported, whereas cases highlighting the prevalence of CD-associated peptic ulcers have been observed and reported in only a few instances. Consequently, greater awareness is warranted and must be exercised for identifying the origins of ulcerative lesions that may be CD-related or -derived.

Drug-eluting bead transarterial chemoembolization (DEB-TACE) is a well-established, minimally invasive interventional treatment for nonresectable hepatocellular carcinoma (HCC). Generally, TACE is regarded as safe and effective with a low complication rate. However, remote gastrointestinal ischemia due to the carryover of embolic material into visceral arteries is a rare but serious complication of TACE. In this report, we present a case of duodenal ulceration with contained perforation and severe necrotizing pancreatitis after TACE in a patient with nonresectable HCC and underlying hepatitis C virus associated with Child-Pugh stage B liver cirrhosis. This patient showed, for the first time, complete endoscopic and clinical recovery within 2 months of conservative treatment. Considering the high mortality rate from surgical intervention in all previously reported patients, the significant recovery potential demonstrated by our case suggests conservative treatment with antibiotics and parenteral nutrition combined with close clinical, radiological, and endoscopic monitoring should be considered in all clinically stable patients without signs of peritonism or septic sequelae.

Acute pancreatitis is a disease with broad spectrum of presentation and has high morbidity and mortality despite of intensive supportive care. Hemorrhagic pancreatitis is one of the calamitous countenance of this ailment unless diagnosed and treated early. Here we are presenting a case of hemorrhagic pancreatitis which presented with seemingly benign symptoms. Thorough clinical evaluation and felicitous use of bedside ultrasonogram (USG) helped to identify this mortal disease. It was complicated due to the presence of ongoing bleed and severe anemia. Patient was transfused and subjected to emergency angiographic embolization. Pancreatitis can be very rarely complicated by duodenal ulceration or hematoma due to the effect of bile, pancreatic juice or elevated pancreatic ductal hypertension, which was also seen in this patient. Despite of all this grave impediments his condition dramatically improved and was discharged.

Background In 2005, a novel virulence factor of Helicobacter pylori was discovered that could increase the risk of duodenal ulceration by stimulating the secretion of IL-8. Hence, it was named duodenal ulcer promoting gene A (dupA). According to statistical analysis, the association between dupA and severe clinical outcomes in Asian and Western countries was evaluate. Methods A systematic search was performed on the association between dupA and its clinical outcomes. Finally, a sensitivity analysis was used to eliminate the significant heterogeneity, as well as random-effect meta-regression was used to assess confounding variables such as cagA and vacA s1. Finally, publication bias was calculated using Egger's and Begg's p value tests. Results Of 182 related studies, 31 reliable studies were included in the quantitative analysis according to inclusion criteria. Sensitivity analysis showed that dupA significantly increases the risk of duodenal ulcer and gastric cancer (OR: 1.58; 95% CI: 1.33–1.88 and OR: 1.27; 95% Cl: 0.99–1.63, respectively), while no significant relationship was observed between dupA and gastric ulcer risk (OR: 1.27; 95% Cl: 0.99–1.63). Based on meta-regression results, cagA and vacA s1 (slope: 0.31; p value: 0.05, slope: 0.23; p value: 0.05, respectively) virulence factors could significantly effect on the association between dupA and the risk of gastric cancer. Due to confounding effects of cagA and vacA s1, the virulence effects of dupA are distorted, and it appears that this gene alone does not increase the risk of gastric cancer. Conclusion Our results confirmed the previous studies, and we found that dupA alone does not appear to increase the risk of gastric adenocarcinoma.

Various drainage procedures in common use for the treatment of duodenal ulceration are critically evaluated. Particular emphasis is laid upon the technique and advantages of anterior pylorectomy.

This article reviews the treatment of duodenal and gastric ulcer when complicated by haemorrhage, performation and obstruction. Support is given for the use of anterior pylorectomy and vagotomy, carried out at the time when the emergency is dealt with, as the preferred long-term procedure in the management of these conditions. Summary 1. Bleeding duodenal ulcers are successfully treated by vagotomy and ligation of the bleeding point in combination with anterior pylorectomy and a personal series of nine cases illustrates this method. There are also certain advantages of such a conservative surgical approach over partial gastrectomy. 2. The technique of anterior pylorectomy for bleeding cases differs slightly from that used for uncomplicated cases. 3. Vagotomy with anterior pylorectomy for perforated duodenal ulceration is a safe and definitive operation. Its advantages over simple suture or emergency partial gastrectomy are indicated on the basis of a review of recent literature and of a small personal series. 4. The technique of anterior pylorectomy for perforated cases differs slightly from that used for uncomplicated and bleeding cases. 5. The treatment of obstructing duodenal ulceration by vagotomy and anterior pylorectomy may have a place. Pylorectomy, if considered inadequate, will not create technical difficulties with an ensuing gastrectomy. 6. The place of vagotomy and anterior pylorectomy in complicated gastric ulceration and gastric erosions is uncertain, but it can be substantiated on present physiological knowledge.

A review of the results of 38 bilateral truncal vagotomics and anterior pylorectomies performed over the past five years is presented.

Over a six-year period from 1961 to 1966, 123 drainage operations were carried out on patients suffering from chronic duodenal ulceration. In this series, long-term follow-up was possible in respect of 85 patients, and the results following the various surgical procedures employed-namely, pyloroplasty, gastro-enterostomy and pylorectomy-in conjunction with bilateral vagotomy are outlined.

Ranitidine HCl is a histamine H2-antagonist which is used in the treatment of benign gastric and duodenal ulceration. In order to improve its bioavailability and half life time, microcapsule is prepared to extend the dose regiment. The aim of this study was to formulate and optimize ranitidine HCl containing microcapsule to prepare a suitable sustained release delivery system using factorial design. Microspheres were prepared using ethylcellulose by solvent evaporation method. The effect of different formulation variables, including stabilizer concentration (1-2 %) and drug/polymer ratio (2:2-1:2) on appearance, and entrapment efficiency was investigated. Data analysis showed that microspheres with optimum entrapment efficiency could be prepared using 2 % span 80, and 1:2 drug/polymer ratio. The results showed spherical shaped microcapsules, and porous, with realeasing time up to 10,55 hours.

Background: Unresectable intrahepatic and hilar cholangiocarcinomas carry a dismal prognosis. Systemic chemotherapy and conventional external beam radiation and brachytherapy have been used with limited success. We explored the use of stereotactic body radiotherapy (SBRT) for these patients. Methods: Patients with unresectable intrahepatic or hilar cholangiocarcinoma or those with positive margins were included in this study. Systemic therapy was used at the discretion of the medical oncologist. The Cyberknife TM stereotactic body radiotherapy system used to treat these patients. Patients were treated with three daily fractions. Clinical and radiological follow-up were performed every three months. Results: 34 patients (16 male and 18 female) with 42 lesions were included in this study. There were 32 unresectable tumors and two patients with resected tumors with positive margins. The median SBRT dose was 30Gy in three fractions. The median follow-up was 38 months (range 8-71 months). The actuarial local control rate was 79%. The median overall survival was 17 months and the median progression free survival was ten months. There were four Grade III toxicities (12%), including duodenal ulceration, cholangitis and liver abscess. Conclusions: SBRT is an effective and reasonably safe local therapy option for unresectable intrahepatic or hilar cholangiocarcinoma.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed medications purchased over the counter to treat acute and chronic pain and inflammation associated with a range of medical conditions.1 It is estimated that NSAIDs are prescribed to about 25% of Canadians for short-term use, but overall use is likely much higher with over-the-counter availability.2 Like any medication, the benefits of NSAIDs should be considered in tandem with the potential adverse effects. Side effects range from the mild and common to the severe and infrequent: dyspepsia, gastric or duodenal ulceration, sodium retention and subsequent hypertension, as well as increased incidence of cardiovascular (CV) adverse events. It was the withdrawal of rofecoxib from the market that brought to light the CV risk of NSAIDs and, in fact, a black-box warning now exists in NSAID product monographs, advising caution when prescribing to patients with ischemic heart disease, cerebrovascular disease and/or congestive heart failure.3 This article focuses on the CV effects associated with NSAID use by reviewing the recent literature on this topic.

Purpose: Malignant obstructive jaundice (MOJ) is relieved by stenting via endoscopic retrograde cholangiopancre atography (ERCP) or percutaneous transhepatic cholangiography and biliary drainage (PTCD). Stent occlusion rates of 30-45% have been reported in literature due to tumor ingrowth or overgrowth. We prospectively evaluated the feasibility and the role of intraluminal brachytherapy (ILBT) in preventing stent blockage in patients with MOJ after PTCD and stenting. Material and methods: Twelve patients with MOJ who underwent PTCD followed by self expanding metallic stent (SEMS) placement were prospectively enrolled in this study. Written informed consent was obtained. Intraluminal bra chytherapy was done once patient was stable and serum bilirubin was less than 2 mg% or 50% of baseline value. On the day of ILBT, 6 French brachytherapy catheters were placed across malignant stricture under fluoroscopic guidance with placement of the tip 1 cm distal to stricture. A dose of 10 to 14 Gy was delivered at 1 cm from central axis of the source. Suitable patients also received external beam radiotherapy (EBRT) with weekly concurrent chemotherapy. Results: All patients tolerated the procedure well with minimal acute and late toxicities. Duodenal ulceration was observed in 1 patient. At a mean follow up of 10.25 months (5-24 months), stents were patent in 10/12 subjects and stent patency duration of 9.8 months (5-22) was reported. Conclusions: Intraluminal brachytherapy post PTCD is feasible and effective in preventing stent occlusion with min imal acute and late toxicities. J Contemp Brachytherapy 2013; 5, 2: 83-88 DOI: 10.5114/jcb.2013.35563

Purpose To evaluate safety of resin microsphere radioembolization (RE) without prophylactic embolization of the gastroduodenal artery (GDA). Materials and Methods Between July 2013 and April 2015, all patients undergoing RE with resin microspheres for liver-dominant metastatic disease were treated without routine embolization of the GDA. Selective embolization of distal hepaticoenteric vessels was performed if identified by digital subtraction angiography, cone-beam computed tomography, or technetium-99m macroaggregated albumin scintigraphy. Resin microspheres were administered using 5% dextrose flush distal to the origin of the GDA in lobar or segmental fashion, with judicious use of an antireflux microcatheter in recognized high-risk situations. Gastrointestinal toxicity was evaluated by the performing physician for at least 3 months. Results RE with resin microspheres was performed in 62 patients undergoing 69 treatments. During planning angiography, embolization of 0 or 1 vessel (median, 1; range, 0–4) was performed in 86% of patients, most commonly the right gastric and supraduodenal arteries. Prophylactic embolization of the GDA was performed in only 2 patients (3%). In 6 treatments (9%), adjunctive embolization was required immediately before RE, and an antireflux microcatheter was used in 14% of treatments. Clinical follow-up was available in 60 of 62 patients (median, 134 d; range, 15–582 d). No signs or symptoms of gastric or duodenal ulceration were observed. Conclusions RE using resin microspheres without embolization of the GDA can be performed safely.

We reported our initial experience in using Elekta volumetric modulated arc therapy (VMAT) and an anatomy-based treatment planning system (TPS) for single high-dose radiosurgery (SRS-VMAT) of liver metastases. This study included a cohort of 12 patients treated with a 26-Gy single fraction. Single-arc VMAT plans were generated with Ergo++ TPS. The prescription isodose surface (IDS) was selected to fulfill the 2 following criteria: 95% of planning target volume (PTV) reached 100% of the prescription dose and 99% of PTV reached a minimum of 90% of prescription dose. A 1-mm multileaf collimator (MLC) block margin was added around the PTV. For a comparison of dose distributions with literature data, several conformity indexes (conformity index [CI], conformation number [CN], and gradient index [GI]) were calculated. Treatment efficiency and pretreatment dosimetric verification were assessed. Early clinical data were also reported. Our results reported that target and organ-at-risk objectives were met for all patients. Mean and maximum doses to PTVs were on average 112.9% and 121.5% of prescribed dose, respectively. A very high degree of dose conformity was obtained, with CI, CN, and GI average values equal to 1.29, 0.80, and 3.63, respectively. The beam-on-time was on average 9.3 minutes, i.e., 0.36. min/Gy. The mean number of monitor units was 3162, i.e., 121.6. MU/Gy. Pretreatment verification (3%-3. mm) showed an optimal agreement with calculated values; mean γ value was 0.27 and 98.2% of measured points resulted with γ < 1. With a median follow-up of 16 months complete response was observed in 12/14 (86%) lesions; partial response was observed in 2/14 (14%) lesions. No radiation-induced liver disease (RILD) was observed in any patients as well no duodenal ulceration or esophagitis or gastric hemorrhage. In conclusion, this analysis demonstrated the feasibility and the appropriateness of high-dose single-fraction SRS-VMAT in liver metastases performed with Elekta VMAT and Ergo++ TPS. Preliminary clinical outcomes showed a high rate of local control and minimum incidence of acute toxicity.

Summary Reason for performing study: Gastric ulcer disease is reported to be a significant cause of morbidity in foals, but the prevalence of ulcers in this population has not recently been evaluated. Objectives: To determine the prevalence of gastric and duodenal ulceration in nonsurviving foals, and the association of ulceration with the body system of primary diagnosis. Secondary objectives were to evaluate a potential association between age and ulcer prevalence and to evaluate the use of antacid medication in the neonatal hospital population during the study years. Methods: Necropsy records were searched for all equine accessions from 1995 to 2006. Foals aged from one day to 6 months were included. Year, age, breed, sex, diagnosis and the presence of glandular, nonglandular and/or duodenal ulceration were recorded. Diagnoses were divided into groups based on the body system of primary diagnosis, with multiple diagnoses possible. A computerised database was searched for antacid treatment of all neonatal admissions. Results: The overall prevalence of ulcers was 22%, with nonglandular ulcers predominating. Ulceration was significantly associated with gastrointestinal disease. There was no significant change in ulcer prevalence over time, although there was a significant decrease in the use of antacid medications in the later study years. Neonatal foals (

The incidence and management of peptic ulcer disease have changed considerably since the first surgical interventions, carried out less than a century ago. Operative techniques refined during the early second half of the twentieth century have become almost obsolete in today's practice for two principal reasons. First, understanding of the aetiology of the disease process has taken a dramatic step forward with the discovery of Helicobacter pylori , now known to be associated with 95% of cases of duodenal ulceration. Second, the pharmacological development of histamine (H 2 )-receptor antagonists and, more recently, proton-pump inhibitors means that the control of acid secretion in the stomach is now achievable without resorting to invasive and often debilitating surgical procedures. Despite these advances, emergency presentations with either haemorrhage or visceral perforation continue to occur with relative frequency and it remains the responsibility of the surgical trainee to understand the fundamentals of patient management in these situations.

BACKGROUND: Despite recent advances and better understanding of the etiology and the pathogenesis of gastrointestinal ulcer diseases, e.g., duodenal ulcer, the molecular events leading to ulcer development, delayed healing, and recurrence remain poorly elucidated. AIMS: After we found that duodenal ulcers did not heal despite increased levels of vascular endothelial growth factor (VEGF), we tested the hypothesis that an imbalance in angiogenic VEGF and anti-angiogenic endostatin and angiostatin might be important in the development and delayed healing of experimental duodenal ulcers. METHODS: Levels of VEGF, endostatin, and angiostatin, and the expression and activity of related matrix metalloproteinases (MMP) 2 and 9 were measured in scrapings of rat proximal duodenal mucosa in the early and late stages of chemically induced duodenal ulceration. Furthermore, animals were treated with recombinant endostatin and MMP 2 inhibitor to test the relationship between MMP2 and endostatin and their involvement in healing of experimental duodenal ulcers. RESULTS: A concurrent increase of duodenal VEGF, endostatin, and angiostatin was noted during duodenal ulceration. Endostatin treatment aggravated duodenal ulcer. Levels of MMP2, but not MMP9, were increased. Inhibition of MMP2 reduced levels of endostatin and angiostatin, and attenuated duodenal ulcers. CONCLUSIONS: Increased levels of endostatin and angiostatin induced by MMP2 delayed healing of duodenal ulcers despite concurrently increased VEGF. Thus, an inappropriate angiogenic response or “angiogenic imbalance” may be an important new mechanism in ulcer development and impaired healing.

Background : In developing countries the prevalence of duodenal ulceration is related to the staple diet and not to the prevalence of Helicobacter pylori. Experiments using animal peptic ulcer models show that the lipid fraction in foods from the staple diets of low prevalence areas gives protection against ulceration, including ulceration due to non-steroidal anti-inflammatory drugs (NSAIDs), and also promotes healing of ulceration. The lipid from the pulse Dolichos biflorus (Horse gram) was highly active and used for further investigations. Further experiments showed the phospholipids, sterol esters and sterols present in Horse gram lipid were gastroprotective. Dietary phospholipids are known to be protective, but the nature of protective sterols in staple diets is not known. The present research investigates the nature of the protective phytosterols. Methods : Sterol fractions were extracted from the lipid in Dolichos biflorus and tested for gastroprotection using the rat ethanol model. The fractions showing protective activity were isolated and identification of the components was investigated by Gas Chromatography-Mass Spectrometry (GC-MS). Results : The protective phytosterol fraction was shown to consist of stigmasterol, beta-sitosterol and a third as yet unidentified sterol, isomeric with beta-sitosterol. Conclusions: Dietary changes, affecting the intake of protective phospholipids and phytosterols, may reduce the prevalence of duodenal ulceration in areas of high prevalence and may reduce the incidence of recurrent duodenal ulceration after healing and elimination of Helicobacter pylori infection. A combination of phospholipids and phytosterols, such as found in the lipid fraction of ulceroprotecive foods, may be of value in giving protection against the ulcerogenic effect of NSAIDs. doi:10.4021/gr328w

The gastroduodenal artery (GDA) is usually embolised to avoid nontarget dispersal before yttrium-90 (Y(90)) radioembolisation to treat liver metastases. In a minority of patients, there is retrograde flow in the GDA. The purpose of this study was to determine if there is any increased risk from maintaining a patent GDA in patients with reversed flow.A retrospective review was performed of all patients undergoing Y(90) radioembolisation at our institution. The incidence of toxicities arising from nontarget radioembolisation by way of the GDA (gastric/duodenal ulceration, gastric/duodenal bleeding, and pancreatitis) and death occurring within 2 months of treatment were compared between the reversed and the antegrade GDA groups.Ninety-two patients underwent preliminary angiography. Reversed GDA flow was found on angiography in 14.1% of cases; the GDA was not embolised in these patients. The GDA was coiled in 55.7% of patients with antegrade GDA flow to prevent inadvertent dispersal of radioembolic material. There was no increased toxicity related to nontarget dispersal by way of the GDA, or increased early mortality, in patients with reversed GDA flow (P0.05).In patients with reversed GDA flow, maintenance of a patent GDA before administration of Y(90) radioembolisation does not increase the risk of toxicity from nontarget dispersal. Therapeutic injection, with careful monitoring to identify early vascular stasis, may be safely performed beyond the origin of the patent GDA. A patent GDA with reversed flow provides forward drive for infused particles and may allow alternative access to the hepatic circulation.

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.

The NSAID class of medications is frequently used for mild to moderate pain. While overall safe, NSAIDs have several important adverse effects including esophageal, gastric and duodenal ulceration which limit their use. This has led to the development of NSAIDs with either less gastrointestinal side effects or concurrent use of medications to prevent NSAID gastrointestinal side effects. While several classes of medications exist for the prevention of gastrointestinal side effects, few combination treatments are available in a single pill. Towards this end, a combination pill of ibuprofen and famotidine (HZT-501, Horizon Therapeutics, Skokie, IL. USA) has been developed.

The word peptic implies ‘gastric-, pepsin- or acid-related’. Peptic ulcer disease (PUD) denotes the presence of gastric and/or duodenal ulceration or erosion. In clinical practice, the term encompasses gastric or duodenal infl ammation due to any etiology, and may be more common in childhood than ulcerative disease. PUD occurs across the pediatric age group. Although etiopathology of PUD is typically related to that of Helicobacter pylori infection, other etiology for PUD is not uncommon in children and requires a different approach in evaluation and therapeutic decisions. Evaluation of PUD includes endoscopy with mucosal biopsy. Noninvasive testing, such as urea breath test, has a role in the follow-up of H. pylori eradication following therapy. Better understanding of pathogenic factors innate to H. pylori infection has enhanced our understanding of associated PUD. This review describes the management of both H. pylori and non-H. pylori PUD.

When surgery is indicated for bleeding duodenal ulcer, the traditional standard of care has been "radical surgical treatment is preferable to conservative therapy since the risk of rebleeding is reduced without an augmentation in morbidity and mortality". This principle is based on two prospective studies published before 1995. Radical surgery at that time consisted of antrectomy, while conservative therapy included oversewing of the bleeding vessel in the ulcer bed and ligation of the gastroduodenal artery (Weinberg procedure). This strategy must be re-evaluated in 2008 in view of our better understanding of the role of Helicopacter pylori in the causation of duodenal ulceration and the decreased risk of post-operative re-bleeding with the use of proton pump inhibitors. The role of surgery has changed. Its aim is no longer to cure the ulcer diathesis but rather to urgently control bleeding in anticipation of ulcer cure with medical therapy.

The familial occurrence of essential tremor combined with (congenital) nystagmus, duodenal ulceration and a narcolepsy-like sleep disturbance caused by an autosomal dominant gene with high penetrance and fairly uniform expressivity is reported in a family of Swedish-Finnish ancestry. Twelve of 17 affected family members had essential tremor which began between 30-40 years of age and which could be controlled temporarily by alcohol; this resulted in alcoholism in several affected individuals. The most severly affected persons showed cerebellar signs which may reflect a possible pathogenetic relationship of the syndrome to the genetic cerebellar atrophies. Nystagmus, observed in 12 of 17 affected family members (eight of whom were also affected with tremor) usually was congenital and accompanied by refractive errors. Duodenal ulcers occurred almost exclusively in individuals with the neurological syndrome, and preceded its onset in some cases. The ulcer disease therefore seems to be a component manifestation of the syndrome and is interpreted as a pleiotropic effect of the gene which also causes the nystagmus, tremor and sleep disturbance.