The Medical Treatment of Gastric and Duodenal Ulcer
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Postgrad. med. J. (August 1968) 44, 603-607. Postgrad Med J: first published as 10.1136/pgmj.44.514.603 on 1 August 1968. Downloaded from The medical treatment of gastric and duodenal ulcer M. J. S. LANGMAN Member of Scientific Staff, M.R.C. Statistical and Gastroenterological Research Units, University College Hospital, London, W.C. 1 THERAPY for gastric and duodenal ulceration has known association between peptic ulceration and in general been based upon rest, frequent meals, hepatic cirrhosis there is no evidence that moder- the avoidance of stress and potential irritants ate alcohol consumption has any real effect such as aspirin and smoking and the initiation upon ulcer incidence or prognosis. Finally no of treatment designed to reduce the corrosive specific dietary item has ever been convincingly quality of the gastric juice. Progress has however shown to be associated with liability to ulcera- been considerably hindered by our poor under- tion. standing of causal mechanisms. Medical treatment has in the past been largely Gastric ulcer tends to be associated with acid based upon the results reported by physicians hyposecretion and some degree of gastritis, while of their clinical experience obtained in uncon- in duodenal ulcer the parietal cell mass is usually trolled trials. Such results are however of little large and there is generally a high level of acid if any value because of the natural tendency for output. But it is not known if the gastric acid both gastric and duodenal ulcer to pursue a Protected by copyright. secretory capacity affects either the short-term remittent course with occasional exacerbations. results of ulcer treatment or the ultimate prog- The technique of the controlled clinical trial has, nosis. There is good evidence that genetic factors particularly in the last 15 years, allowed for associated with the ABO blood groups influence more rigorous testing of the remedies usually the behaviour (Langman & Doll, 1965) and prob- advocated. Such trials have been of particular ably also the incidence (Aird et al., 1954) of value in the study of gastric ulceration where gastric and duodenal ulceration. The gastro- comparative radiological studies can be per- duodenal mucosa contains substantial quantities formed before and after a course of treatment. of the blood group substances (Szulman, 1960, Duodenal ulcer has been harder to study because 1962) and it is tempting to consider that the clear radiological definition of an ulcer crater in different ABO blood group substances vary in the presence of a deformed duodenal cap can the protective qualities which they give against be difficult if not impossible. This problem is ulceration. There is, however, no clear evidence of special significance because the duodenal in support of such an effect, which would in ulcer in the undeformed cap is a comparative http://pmj.bmj.com/ any case be likely to be small because the ABO rarity. Conclusions from studies of patients with associations are themselves comparatively weak. such lesions may have little relevance to the It is likely that environmental influences are of results which might be obtained in individuals primary importance in influencing the incidence with permanent duodenal abnormalities due to of ulcer, a view emphasized by the changing scarring. ratio of gastric to duodenal ulceration in the The value of short-term clinical studies of last 100 years and by the striking geographical duodenal ulcer treatment can be increased by on September 30, 2021 by guest. variations in ulcer incidence. There are, however, adding comparisons of ulcer symptoms during no clear indications of the basic mechanisms treatment, but symptoms or their absence are underlying these environmental factors. not necessarily a true guide to the activity of Tobacco smoking has been demonstrated on ulceration. Another approach has been to com- several occasions to be associated with an in- pare the relapse or complication rates in patients creased mortality from ulcer but the tendency given different treatments after their initial symp- is probably greater for gastric than duodenal toms have settled. This type of study has the ulcer (Hammond & Horn, 1958). The latter is disadvantage that treatment may have to be the commoner disease and smoking is, therefore, continued for prolonged periods of two or more unlikely to be of primary importance in the years if sufficient time is to be allowed for any causation of duodenal ulceration (nor probably differences between groups to be observed. indeed in gastric ulceration). In spite of the After consideration of these problems it 604 M. J. S. Langman Postgrad Med J: first published as 10.1136/pgmj.44.514.603 on 1 August 1968. Downloaded from becomes clear why progress has not been more (Evans, 1954; Doll, Friedlander & Pygott, 1956; rapid in defining the value of specific treatments Truelove, 1960) and though the evidence is not for gastric or duodenal ulcer. so satisfactory for duodenal ulcer such studies as In theory it would be preferable to consider have been performed have similarly failed to medical treatment of three types. show any real differences. (a) Management of acute symptoms. Some patients do find however that fried foods (b) Treatment designed to heal the ulcer. cause pain and therefore they are probably best (c) Prevention of relapse. avoiaed. It also seems sensible to advise against However, the treatments which promote the the taking of spirits. healing of ulcers are few and none has been There is no evidence to suggest that, once definitely shown to prevent relapse. It is there- remission has occurred, any particular food will fore preferable to try to define separately the confer protection against relapse. value of each treatment at present available. Smoking General measures Though it is commonly stated that ulcer patients should smoke little if at all there is only Bed rest scanty evidence to support this view. A higher It is well known that ulcer symptoms remit proportion of smokers than non-smokers has rapidly when patients are admitted to hospital, been found in individuals with gastric and with and there is evidence that gastric ulcers do in duodenal ulcers than might have been expected fact heal more readily during inpatient than out- from comparable control populations and it has patient care (Doll & Pygott, 1952). However, also been shown that cessation of smoking pro- there is no good evidence that duodenal ulcers motes the short-term healing of gastric ulcers tend to heal during periods of rest, though (Doll, Jones & Pygott, 1958). There is no useful Protected by copyright. equally there is none to the contrary. evidence about the effect of stopping smoking on No satisfactory evidence is available to show the healing of duodenal ulcers nor that smoking whether a period of in-patient treatment effects increases the chances of relapse of gastric or the later course of the ulcers. duodenal ulcers. However, on general clinical Diet grounds it seems reasonable to advise against the In the past it has been conventional to give the habit. ulcer patient a diet graduated from one which consisted mainly of milk and milk-products to a Drugs final level where foods were still restricted in Alkalis type and were usually sieved or mashed. The There is considerable disparity between the experimental evidence favouring the use of any brief period of minutes in which an alkali will such diets is however extremely poor. reduce gastric acid and the prolonged period, Nicol (1939) found that the mean acidity of often of several hours for which symptoms will gastric contents when sampled hourly through a be relieved. http://pmj.bmj.com/ naso-gastric tube was little different in patients In vitro tests have shown that sodium bicar- taking milk, cream and vegetable puree every bonate, calcium carbonate and magnesium oxide 2 hr and in those individuals who took a light or hydroxide are the most efficient preparations diet composed of four main meals and 150 ml for acid neutralization (Piper & Fenton, 1964). of milk at night. By a similar technique Lennard But there is little evidence to suggest that any Jones & Babouris (1965) showed that the pH of preparation even when given in large doses affects samples of gastric juice collected every hour ulcer healing. Price & Sanderson (1956) estimated on September 30, 2021 by guest. differed little in patients taking a diet of their that 60 g of sodium bicarbonate, given daily own choice and in those taking conventional by intra-gastric drip, would be needed to keep gastric diets. The only factor which appeared to the pH of the stomach contents above 4-0 in affect pH to any marked degree was the timing those with gastric ulcer: clearly in duodenal ulcer of meals. A free-choice diet taken at 2-hourly even larger amounts would be required. The intervals tended to reduce the swings of acidity value of a milk-alkali drip in healing duodenal produced by the same diet given at 4-hourly ulcer rather than relieving symptoms has never intervals. been proved and such treatment has been demon- This evidence from sampling studies is sup- strated to be of little, if any, value in gastric ported by the results of controlled clinical trials. ulceration. There is no evidence that any particular diet The intensive use of alkalis in the treatment of will influence the healing rate of gastric ulcer, duodenal ulcer needs more rigorous testing, but Medical treatment of gastric and duodenal ulcer 605 Postgrad Med J: first published as 10.1136/pgmj.44.514.603 on 1 August 1968. Downloaded from it may well be that treatment would be limited the healing of gastric ulcers. The drug is of by the known side-effects of the therapy. Mag- particular value in treating patients while nesium salts tend to cause diarrhoea, calcium ambulant and at work, but unfortunately its use carbonate and sodium bicarbonate can induce is frequently attended by fluid retention which alkalosis, and calcium salts can also cause hyper- can be sufficiently severe to cause congestive calcaemia.