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Biomedical subjects

J G Penston

Publications and source records attributed to J G Penston.

At least 19 recordsLinked to original sources
PubMed1997

Eradication of Helicobacter pylori: an objective assessment of current therapies.

The purpose of the present review was to determine objectively the optimal treatment for the eradication of H. pylori amongst the currently used regimens. A comprehensive literature search provided a data-base relating to the following treatments: dual therapy with an anti-secretory drug plus either amoxycillin or clarithromycin; standard triple therapy, with or without additional anti-secretory drugs; proton pump inhibitor triple therapy; and H2-receptor antagonist triple therapy. Emphasis was placed on intention-to-treat analyses of eradication rates using all of the available evidence. The criteria used to select the optimal treatment were efficacy (eradication rates), frequency of side-effects, simplicity of the regimen (number of tablets per day and duration of treatment) and cost. The analysis showed that proton pump inhibitor triple therapy (that is, a proton pump inhibitor plus any two of amoxycillin, clarithromycin or a nitroimidazole) was the preferred treatment for the eradication of H. pylori. In particular, the 1-week, low-dose regimen with omeprazole plus clarithromycin plus tinidazole produced the highest eradication rates (> 90%) with the lowest frequency of side-effects and at only modest cost.

Anti-Bacterial Agents↗
PubMed1996

Review article: clinical aspects of Helicobacter pylori eradication therapy in peptic ulcer disease.

BACKGROUND AND AIMS: Although the role of H. pylori in peptic ulcer disease is no longer in dispute, certain aspects of eradication therapy in this condition have yet to be settled. Uncertainties still surround the relationship between Helicobacter pylori status and ulcer healing, the efficacy of eradication therapy in alleviating acute symptoms and healing ulcers, and the prognosis after eradication with respect to recurrence of symptoms, ulcers and complications. The present literature review, encompassing studies published up to October 1995, specifically addresses these issues. RESULTS: Pooled data show that eradication therapy heals > or = 90% of duodenal ulcers and > or = 85% of gastric ulcers, while individual studies repeatedly confirm that it is more effective at healing ulcers than conventional treatment with anti-secretory drugs. Recent reports indicate that triple therapy regimens for 1 week, provided they include an anti-secretory drug, are sufficient to achieve high rates of healing and rapid symptom relief. A detailed analysis of the data, particularly those from studies reporting healing rates in relation to H. pylori status after eradication therapy, provides strong evidence that eradication of H. pylori produces ulcer healing. Follow-up studies show that ulcer recurrence and complications are rare after eradication treatment in patients with either gastric or duodenal ulcer disease. However, while ulcer symptoms are infrequent during follow-up, a proportion of patients appear to develop gastrooesophageal reflux after eradication. CONCLUSIONS: H. pylori eradication is highly effective in promoting ulcer healing and preventing subsequent ulcer recurrence. These beneficial effects of eradication therapy are observed in patients with either gastric or duodenal ulcers which are associated with H. pylori infection.

Anti-Bacterial Agents↗
PubMed1996

Eradication of Helicobacter pylori in general practice.

OBJECTIVES: To determine the current management of patients with Helicobacter pylori infection in general practice with regard to the selection of patients, testing for the presence of the organism, the choice of eradication therapy and the occurrence of symptoms during follow-up. DESIGN: Cross-sectional survey involving the retrospective collection of data from patient medical records. SETTING: Five general practices in the Fife region of Scotland during June and July 1995. MAIN OUTCOME MEASURES: The proportion of patients appropriately selected for eradication therapy and the success of treatment as assessed by remission of symptoms during follow-up. RESULTS: Of 154 patients studied, 80% received eradication therapy for peptic ulcer disease, the remainder for non-ulcer dyspepsia or gastrooesophageal reflux. Fifty-six different regimens were used, the most common combination of drugs being omeprazole plus amoxycillin. H. pylori status was known in only one-third of patients before treatment and in only 15% after treatment. More than half of patients complained of recurrent symptoms of dyspepsia during follow-up after eradication therapy and 47% required further treatment. In terms of the selection of patients and testing for H. pylori, the overall management using eradication therapy was acceptable in less than half of patients. In particular, the management of patients with ulcer disease associated with either ulcerogenic drugs or previous complications failed to provide the essential protection against the high risk of future haemorrhage or perforation. CONCLUSIONS: The findings of this study indicate an urgent need for improved education if therapy for the eradication of H. pylori is to be used appropriately and safely.

Adult↗
PubMed1996

A survey of dyspepsia in Great Britain.

OBJECTIVES: To determine the prevalence of dyspepsia in the adult population of Great Britain and to describe the clinical features, treatment, effect of dyspepsia on daily lives and perceptions of peptic ulcer disease. DESIGN: Cross-sectional survey of the adult population using structured questionnaires. SETTING: Subjects interviewed at more than 150 sampling points in England, Scotland and Wales in November 1994. SUBJECTS: A representative sample of the adult population comprising 2112 subjects, aged 16 years or more. MAIN OUTCOME MEASURES: The prevalence of dyspepsia in the adult population and the frequency of various characteristics in dyspeptic subjects. RESULTS: The prevalence of dyspepsia was 40%. Upper abdominal pain and heartburn were the most frequently reported symptoms. Solitary symptoms were uncommon and there was frequent overlap between 'ulcer-like' and 'reflux-like' dyspepsia. Forty-six per cent of dyspeptic subjects reported moderate or severe symptoms. More than half of symptomatic subjects took medication and 22% had visited their GP during the previous year. Overall, 2% of the survey sample had been absent from work due to dyspepsia. Awareness of the factors precipitating or aggravating peptic ulcer disease was poor, particularly in relation to anti-inflammatory drugs. CONCLUSIONS: The present study emphasizes the magnitude of the problem of dyspepsia in the adult population of Great Britain. The survey also shows that the public in general, and patients in particular, require more information if they are to avoid factors known to damage the upper alimentary tract.

Adolescent↗
PubMed1995

Pentagastrin increases pepsin secretion without increasing its fractional synthetic rate.

We studied the effects of increasing doses of pentagastrin on gastric secretion of pepsin and on incorporation of L-[1-13C]leucine into gastric aspirate protein as an index of pepsin synthesis. Pentagastrin (0.25-4.0 micrograms.kg-1.h-1) significantly increased pepsin output from basal 76 mg/h to < or = 181 mg/h but did not significantly alter incorporation of L-[1-13C]leucine from the basal fractional synthetic rate of 3.63 +/- 0.05%/h. In four subjects in whom infusion of tracer leucine was continued for > 1 day, aspiration of pepsin between 24 and 27 h demonstrated that plateau 13C labeling of leucine in pepsin had been attained, but at a value that was only 48% of the 13C labeling of plasma alpha-ketoisocaproic acid (alpha-KIC) [0.730 +/- 0.02 (SE) vs. 1.520 +/- 0.14 atoms %excess]. This suggests that actual rates of pepsin synthesis were approximately double those calculated on the basis of alpha-KIC labeling. The results are consistent with an interpretation that increasing doses of pentagastrin cause increased secretion of pepsinogen by recruitment of gastric chief cells, each synthesizing pepsinogen at an unaltered rate. Plateau 13C enrichment of alpha-KIC may not be a valid surrogate for plateau 13C leucine enrichment when fractional synthetic rates of some secreted proteins are calculated.

Adult↗
PubMed1994

Review article: Helicobacter pylori eradication--understandable caution but no excuse for inertia.

The long-term management of patients with peptic ulcer disease is unsatisfactory, as judged by the persistently high levels of haemorrhage, perforation and death from this condition in Western countries. Although ulcer recurrence and complications can be prevented, many patients with peptic ulcer disease fail to receive the benefits of modern therapeutic regimens. In recent years, eradication of Helicobactor pylori has been promoted as a 'cure' for peptic ulcer disease and, while such claims are premature, there can be little doubt that this treatment--when successful--dramatically improves the medium-term prognosis of ulcer patients. However, in general, clinicians have given this promising therapeutic advance a lukewarm welcome. The aim of this detailed review of the literature is to remove the uncertainty and confusion surrounding many aspects of eradication therapy. Estimates are provided of the eradication rates after either triple therapy or the combination of omeprazole plus amoxycillin, and the sources of variation in published studies are discussed. Problems associated with eradication therapy, including side effects, compliance and re-infection, are addressed in order to ascertain the extent and clinical significance of each factor. In addition, studies reporting the outcome of patients with peptic ulcer disease after eradication are assessed with reference to both ulcer recurrence and complications. The result of the review is to dissipate much of the scepticism concerning eradication therapy. However, whilst acknowledging the efficacy of eradication therapy, its limitations have also to be recognized. By itself, it does not provide the complete answer to peptic ulcer disease. For some ulcer patients, eradication therapy is the preferred option; for others, prophylactic therapy with H2-receptor antagonists is more suitable. Guidelines are proposed for the selection of patients for each alternative therapy. The crucial point is that patients with peptic ulcer--excluding the small proportion with a mild form of the disease--require positive, long-term management consisting of either continuous prophylaxis with H2-receptor antagonists or the eradication of Helicobacter pylori.

Anti-Bacterial Agents↗
PubMed1993

A placebo-controlled investigation of duodenal ulcer recurrence after withdrawal of long-term treatment with ranitidine.

Ninety-two patients with duodenal ulcer disease, who had received long-term continuous treatment with ranitidine for an average of 7.5 years, participated in a double-blind, placebo-controlled study to determine whether stopping ranitidine resulted in ulcer recurrence. Patients were randomized to continue with ranitidine (n = 46) or to receive placebo (n = 46) and were followed up for six months. Treatment failure was defined as the first symptomatic recurrence of ulcer. The occurrence of epigastric pain during the follow-up period was significantly less frequent in the ranitidine group (13%) than in the placebo group (43%) (P = 0.001). At six months, 9% of the ranitidine group had developed ulcer recurrence, compared with 48% in the placebo group (P < 0.001, logrank test). Multivariate analysis using the Cox proportional hazards model showed that younger age (P = 0.041) and a long history of ulcer disease (P = 0.025) were risk factors for ulcer recurrence but gender, smoking and duration or dose of previous ranitidine treatment were not predictive of relapse during treatment with placebo. In conclusion, withdrawal of ranitidine after more than five years of continuous treatment results in almost half of the patients developing symptomatic ulcer recurrence within six months. Thus, long-term continuous therapy does not alter the natural history of duodenal ulcer disease. Younger patients and those with a long history of ulcer disease appear to be at increased risk of developing ulcer recurrence if long-term treatment is withdrawn.

Age Factors↗
PubMed1993

Trends in morbidity and mortality from peptic ulcer disease: Tayside versus Scotland.

Recent studies have shown that the prophylactic use of H2-receptor antagonists reduces both ulcer recurrence and the risk of ulcer complications. Despite these results, epidemiological studies have failed to show any evidence of an effect of gastric anti-secretory drugs on complicated ulcer disease in the community. Since 1979, it has been the policy of the gastroenterology department at Ninewells Hospital in Tayside to recommend long-term, continuous therapy with H2-receptor antagonists for patients with peptic ulcer; in contrast, prophylactic therapy is less commonly used in the rest of Scotland. The difference in the management of peptic ulcer between Tayside and Scotland presented an opportunity to study the population effects of the widespread use of continuous H2-receptor antagonists on the morbidity and mortality from ulcer disease. This study compared the trends in hospital admissions, gastric surgery, haemorrhage, perforation and mortality from ulcer disease using data supplied by the Information and Statistics Division of the Common Services Agency, Scottish Health Service, Edinburgh. During the 1980s, hospital admissions for peptic ulcer declined significantly in Tayside, whereas in Scotland there was no obvious downward trend. Gastric surgery for ulcer disease declined throughout Scotland although the fall was significantly steeper in Tayside than in the rest of Scotland. For the population in general, the rate of perforation decreased faster in Tayside than in the rest of Scotland, although the difference was not significant. The rate of admissions for ulcer haemorrhage declined substantially in Tayside whereas there was little change in Scotland as a whole. The decrease in mortality from ulcer disease in all groups except younger females was more marked in Tayside than in Scotland, although the differences were not significant. The magnitude of the differences between Tayside and Scotland, and in particular the consistency of these results across a broad range of indicators of ulcer disease, suggests that the policy of prescribing long-term, continuous therapy with H2-receptor antagonists has reduced both uncomplicated and complicated peptic ulcer in the community in Tayside.

Adult↗
PubMed1993

A decade of experience with long-term continuous treatment of peptic ulcers with H2-receptor antagonists.

Patients with peptic ulcer disease are troubled by recurrent episodes of ulcer pain, and remain at risk of developing the serious and occasionally lethal complications of haemorrhage and perforation. As the disease is chronic and persists over many years, a long-term strategy for the management of patients with peptic ulcer is required. Continuous, long-term treatment with H2-receptor antagonists successfully achieves the dual objectives of preventing painful ulcer recurrence and reducing the risk of complications. During nine years of continuous therapy with ranitidine, more than 80% of patients with duodenal ulcers remain free from symptomatic ulcer recurrence, less than 2% suffer from ulcer haemorrhage, and the risk of perforation is 0%. Similar beneficial effects of long-term treatment have been observed in patients with gastric ulcer. Long-term continuous treatment with H2-receptor antagonists may not alter the natural history of ulcer disease. Even after seven years of continuous therapy with ranitidine, ulcers recur in 50% of patients within six months of stopping treatment. Hence, long-term therapy with H2-receptor antagonists may need to be continued beyond 10 years. Patients with peptic ulcer who are elderly, those taking NSAIDs, aspirin or anti-coagulants, those with a previous history of an ulcer complication and those with serious co-existent disease are at increased risk from haemorrhage and perforation. These patients should receive long-term prophylactic therapy with an H2-receptor antagonist.

Histamine H2 Antagonists↗
PubMed1992

Complications associated with ulcer recurrence following gastric surgery for ulcer disease.

The present study is an attempt to assess the risks of the complications associated with recurrent ulcers in patients who have undergone gastric surgery and to determine whether these risks differ from those observed in patients receiving long term maintenance treatment with H2-receptor antagonists for ulcer disease. One hundred and thirty studies reported in the literature during the past three decades have been analysed to determine both the approximate rate of ulcer recurrence and the proportion of patients with recurrent ulcers who have presented with either haemorrhage or perforation following the various types of gastric surgery for ulcer disease. From these data, estimates of the risks of haemorrhage and of perforation during the years following gastric surgery have been calculated. Vagotomy and antrectomy is associated with a low risk of ulcer recurrence (less than 1%) and the risk of complications in later years is accordingly very small (less than 0.5%). Partial gastrectomy, although associated with low recurrence rates, has a higher risk of complications (1.3% for haemorrhage, 0.3% for perforation) because the proportion of recurrent ulcers that present with haemorrhage or perforation is high (33% and 8%, respectively). Truncal vagotomy plus drainage (TV + D) and highly selective vagotomy (HSV) are associated with recurrence rates of 9% and 12%, respectively, but ulcer recurrences following these operations are less frequently accompanied by complications then recurrences after gastric resection and, as a result, the risks of haemorrhage (1.7% for TV + D; 1.3% for HSV) are similar to the risks after gastric resection. During long term (five years or more) maintenance treatment with H2-receptor antagonists, the risks of haemorrhage and perforation are less than 2% and less than 0.5%, respectively. It appears, therefore, that the likelihood of developing haemorrhage or perforation following gastric surgery is of the same order as that during maintenance treatment with H2-receptor antagonists, at least during the first decade of follow-up.

Histamine H2 Antagonists↗
PubMed1992

Mallory-Weiss tears occurring during endoscopy: a report of seven cases.

Mallory-Weiss tears occurring during the course of upper gastrointestinal endoscopy are apparently rare. The present report describes seven cases of iatrogenic gastro-oesophageal tears encountered during 10,000 endoscopic examinations over a period of six years. Five of the seven patients were female and six patients were aged 75 years or older. Six patients had hiatal hernias. The site of the mucosal tear was similar in all patients, extending from a V-shaped breach at the gastro-oesophageal junction inferiorly along the lesser curve for a variable distance of up to 8 cm. Neither retching nor struggling during the procedure contributed to the development of the lesion in any of the patients. One patient suffered from a haematemesis which required transfusion, and in a further patient the tear resulted in a haematemesis and gastric perforation necessitating laparotomy. The study indicates that Mallory-Weiss tears complicating endoscopy occur especially in elderly, female patients with hiatal hernias. The importance of admitting patients with this complication to hospital for overnight observation is recommended in view of the possible development of haemorrhage or perforation.

Age Factors↗
PubMed1992

Review article: maintenance treatment with H2-receptor antagonists for peptic ulcer disease.

In recent years a number of different strategies for managing patients with peptic ulcer disease have become available. The present review discusses the relative merits of each form of treatment. Intermittent treatment (whether given in response to symptoms or as a prophylactic regimen prescribed seasonally or at weekends) fails to prevent ulcer recurrence and leaves patients at risk of haemorrhage and perforation. Anti-Helicobacter pylori therapy, although useful in certain circumstances, cannot be recommended for all patients with ulcer disease because of side effects and, in any case, requires further assessment of efficacy. Gastric surgery reduces ulcer recurrence and complications, but operations which have a low incidence of side effects are associated with higher rates of ulcer recurrence, particularly when patients are followed up for more than 10 years. Long-term continuous maintenance treatment with H2-receptor antagonists for 5 or more years effectively prevents ulcer recurrence in the majority of patients and significantly reduces the risk of ulcer complications. In addition, maintenance treatment has proved to be safe and is well tolerated by patients. Maintenance treatment with H2-receptor antagonists is the preferred option for the management of patients with peptic ulcer disease.

Antacids↗
PubMed1992

Nine years of maintenance treatment with ranitidine for patients with duodenal ulcer disease.

Four hundred and sixty-four patients with duodenal ulcer disease received continuous maintenance treatment with ranitidine for up to 9 years. Treatment failure was defined as either the first symptomatic recurrence of ulcer or the first ulcer recurrence accompanied by haemorrhage. Life tables were constructed using the Kaplan-Meier product-limit method; comparisons of survival curves were performed using the log-rank test; and multivariate analysis was carried out using the Cox proportional hazards model. Results. The proportion of patients remaining free from symptomatic recurrence of ulcer during maintenance treatment with either 150 mg/day or 300 mg/day ranitidine was: 95% at 1 year; 88% at 3 years; 86% at 5 years; and 81% at 7 and 9 years (95% C.I. 76-86%). Young age and the absence of exposure to non-steroidal anti-inflammatory drugs (NSAIDs) at the time of diagnosis of ulcer were shown to increase the likelihood of developing ulcer recurrence. The rate of ulcer recurrence after 9 years of maintenance treatment (17%) was significantly less than that after 5 years without active anti-ulcer therapy (80%), P = 0.0001. The proportion of patients who remained free from ulcer haemorrhage during maintenance treatment was: 99.1% at 1 year and 98.1% at 5 and 9 years (95% C.I. 96.7-99.6%). The risk of haemorrhage was significantly greater in patients who were not receiving active treatment (12.4% at 5 years) than in patients receiving maintenance treatment (less than 2% at 9 years), P = 0.0001 (log-rank test). Patients who had originally presented with haemorrhage had an increased risk of further ulcer bleeding compared with patients who presented with pain (P = 0.0013). A significantly greater proportion of patients with NSAID-associated duodenal ulcers remained free from ulcer recurrence during maintenance treatment compared with patients suffering from 'idiopathic' ulcers (P = 0.0238), although there was no difference between the two groups in respect of haemorrhage during maintenance treatment. Conclusions. (a) Continuous maintenance treatment with ranitidine for up to nine years successfully prevents ulcer recurrence in more than 80% of patients with duodenal ulcer disease. (b) Young age increases the risk of ulcer recurrence during maintenance treatment with ranitidine. Ulcers associated with NSAID-intake at the time of diagnosis have a lesser risk of recurrence during maintenance treatment. (c) The risk of haemorrhage in patients with ulcer disease receiving maintenance treatment with ranitidine for nine years was less than 2% compared with greater than 12% in untreated patients observed for 5 years.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1992

Maintenance therapy in duodenal and gastric ulcer disease: survey of practice amongst British gastroenterologists.

We have used a postal questionnaire to obtain data on the practice of maintenance therapy for peptic ulcer disease by members of the British Society of Gastroenterology. Completed questionnaires were returned by 434 members. Ninety-six per cent used maintenance therapy for patients with duodenal ulcer and 81% for gastric ulcer. Maintenance therapy was considered to be safe (duodenal ulcer 91%; gastric ulcer 78%), acceptable to patients (duodenal ulcer gastric ulcer 89%; gastric ulcer 80%) and to reduce the incidence of ulcer complications (duodenal ulcer 81%; gastric ulcer 68%). There was consensus that increasing age of patient, current use of non-steroidal anti-inflammatory drugs, previous ulcer complications, and ulcer relapse after surgery were relatively strong indications for maintenance therapy. However, the proportion of patients who received maintenance therapy varied widely amongst respondents (from < 10% to > 50%). There was no agreement on the optimal duration of therapy, nor on management of patients who relapsed during maintenance therapy. It appears that the criteria for use of maintenance therapy need to be better defined, and that established knowledge about the practice of maintenance therapy should be better disseminated and acted upon.

Age Factors↗
PubMed1991

Hiatal hernial ulcers: clinical features and follow-up.

We describe the clinical features and therapeutic outcome in 49 patients in whom benign gastric ulceration of an hiatal hernia was demonstrated endoscopically. Hiatal hernia ulcers accounted for 10% of all benign gastric ulcers. The typical patient was an elderly female with a history of dyspepsia who was receiving non-steroidal anti-inflammatory drugs. Twenty-seven (55%) patients had evidence of haemorrhage (acute in 15; chronic in 12) from the hiatal hernial ulcer at presentation. In 16 (33%) patients, symptoms attributable to haemorrhage constituted the sole clinical evidence of the hiatal hernial ulcer. Acute haemorrhage from hiatal hernial ulcers was associated with non-steroidal anti-inflammatory drug (NSAID) treatment (P less than 0.05). Chronic blood loss from hiatal hernial ulcers was associated with female gender (P less than 0.005) but not with NSAID treatment. Hiatal hernial ulcers healed slowly in response to medical treatment with H2-receptor antagonists (median time to healing 12 weeks). Surgical treatment may be the therapy of choice for hiatal hernial ulcers because of the high complication rate, poor response to medical therapy, and the apparent predominance of mechanical aetiological factors.

Adult↗
PubMed1990

Long-term maintenance treatment of gastric ulcers with ranitidine.

One hundred and twenty patients with gastric ulcer disease, who had been receiving maintenance treatment with ranitidine (150 or 300 mg/day) for periods up to 7 years, were studied retrospectively. The proportion of patients remaining free from symptomatic recurrence of ulcer during maintenance treatment was 97% after 1 year; 90% after 3 years; and 79% after 5 years. No patient developed haemorrhage or perforation during maintenance treatment. None of the demographic features was shown to be associated with a significantly increased risk of ulcer recurrence during maintenance treatment. Comparison of the recurrence rates during maintenance treatment with those during periods without active anti-ulcer therapy, using life table and incidence density analysis, showed a significant difference in favour of maintenance treatment. We conclude that maintenance treatment with ranitidine for 5 years significantly reduces the risk of symptomatic ulcer recurrence in patients with gastric ulcer.

Adult↗