Article pp.187-189 du Vol.12 n°3 (1982)

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i d i t o r l a i

E n d o s c o p y in t h e m a n a g e m e n t o f d u o d e n a l u l c e r

M.J.S. L A N G M A N

U n i v e r s i t y D e p a r t m e n t of T h e r a p e u t i c s , C i t y H o s p i t a l , N o t t i n g h a m ( E n g l a n d )

L'endoscopie dans le traitement de I'ulc~re duod(~nai

Prior to the introduction of flexible upper gastro- intestinal endoscopy it was impossible to decide whether or not radiological duodenal deformity was associated with active ulceration, and even in those with what s e e m e d to be active ulcers within an undeformed cap it was still not possible to be sure that apparent breaches of mucosal continuity were in fact just such. W e are n o w able to decide whether or not treatments will p r o m o t e ulcer healing, and once healing has o c c u r r e d relapse rates can be com- pared whilst patients continue under different clinical regimens.

Whilst repeated e n d o s c o p y has proved invaluable in the formal assessment of treatments its value in ordinary m a n a g e m e n t once a diagnosis has been established is p r o b a b l y minimal. T h r e e treatments are well-established as p r o m o t i n g ulcer healing, histamine H2 antagonists, and there is little reason to believe that s y m p t o m a t i c or healing responses will differ for cimetidine or ranitidine, chelated bismuth and carbenoxolone s o d i u m and very recently sucral- fate. T h e apparent healing value of these treatments varies from c o u n t r y to country, probably due to two factors, the underlying natural, untreated response rates within groups presenting in different places, and perhaps to other extraneous factors notably the intensity of c o n c u r r e n t antacid treatment. W h e r e

<< natural 7) healing rates are high the value of pro- moting agents will be correspondingly diminished.

For histamine H2 antagonist treatment it is n o w clear that the length or intensity of an initial healing treatment or the length or intensity of subsequent maintenance t r e a t m e n t has no material effect upon outcome [1, 3]. This is scarcely surprising because the acid essentially serves a permissive role in cir- cttmstances where o t h e r extraneous and as yet un-

known factors operate. A fair analogy would be the role of roads in permitting m o t o r accidents. T h e s e are due to collisions between vehicles which can only take ptace because roads are there. T h e abolition of the use of roads would stop accidents occur- ring, but the pattern of accidents would return as before once traffic resumed.

It has been suggested that carbenoxolone sodium and chelated bismuth treatment in short courses will affect ulcer behaviour once treatment ceases [4, 5]. This m a y be so, b u t is inherently surprising for if carbenoxolone, as is believed, has cytoprotec- tive properties, and chelated bismuth acts by forming a resistant barrier to acid peptic digestion then there is no reason why prolonged benefit should necessarily be obtained.

It follows that once the presence of ulceration has been firmly established clinical responses can be judged symptomatically. In general symptomatic and healing responses tend to r u n in parallel, b u t if responses do differ n o h a r m is done. Thus, there is no reason to believe that the patient who loses his symptoms but whose ulcer has actually failed to heal is at any ultimate disadvantage when treatment ceases. Conversely, if symptoms continue una- bated then n o sensible clinician will persist with anti-ulcer treatment without reviewing the general position. Pragmatic m a n a g e m e n t therefore seems completely justifiable.

If we turn to d u o d e n a l ulcer associated with hae- matemesis and melaena the position is essentially the same. In the past d u o d e n a l ulcer bleeding except in those individuals with continued and severe bleeding in hospital who were o p e r a t e d upon was essentially m a n a g e d expectantly. T h e chances of relapse

Address for reprints: M.J.S. LANGMAN, University Department of Therapeutics, City Hospital, Nottingham (England).

Key-words : duodenum, endoscopy, duodenal ulcer, complications, follow-up, treatment.

Mots-clds : duod6num, endoscopic, ulc&e duod6nal, complications, surveillance, traitement.

Acta Endoscopica Volume 12 - N ~ 3 - 1982 187

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as judged b y r e c u r r e n c e of bleeding were low, a b o u t 20 % in the ensuing five years in the United King- d o m [6], a n d in such circumstances the case for ritual t r e a t m e n t with an antisecretory agent following hospital discharge m u s t be extremely doubtful.

Nevertheless it seems likely that the bulk of patients with recent d u o d e n a l ulcer bleeding will n o w receive at least o n e or t w o m o n t h s intensive treatment, although, again in the United K i n g d o m , but there

is no r e a s o n to believe circumstances differ elsewhere, the relapse r a t e after a year was only 7 % .

A case for continued t r e a t m e n t can perhaps be m a d e where patients are elderly, thus the risk of

death f r o m ulcer complications rises steeply in the elderly and a d e t e r m i n e d a t t e m p t at prophylaxis m a y be justifiable. T h e cenventional answer to this pro- blem has been to r e c o m m e n d earlier a n d m o r e frequent operation, b u t there is a good case for believing that such a policy, at least in part, replaces death by bleeding b y d e a t h f r o m postoperative c o m - plications. A n y drug t r e a t m e n t associated with a mortality rate of 1 % w o u l d be instantly withdrawn, yet the risk of elective surgery for duodenal ulcer m a y be of at least this order in elderly people. T h e point is b e c o m i n g of increasing importance in the United K i n g d o m , a n d elsewhere, where ulcer is p r o - gressively b e c o m i n g a disease of the elderly.

REFERENCES 1. SAUNDERS J.H.B., WORMSLEY K.G. - - Long-term

e f f e c t s and after-effects of treatment of duodenal ulcer with metiamide. Lancet, 1977, 1, 765-767.

2. GUDMAND-HYER E., JENSEN B.K., KRAG E., RASK-MADSEN J., RAHBEK I., RUNE S.J., WULFF H.R. - - Prophylactic effect of cimetidine in duodenal ulcer disease. British Medical Journal, 1978, 1, 1095-

1097.

4.

5.

MARTIN D.F., HOLLANDERS D., MAY S . J . , RA- VENSCROFT M., TWEEDLE D.E.F., MILLER J.P.

- - D i f f e r e n c e in r e l a p s e rates of d u o d e n a l u l c e r after healing with cimetidine or tripotassium dicitratobismu- tbate. Lancet, 1981, 1, 7-10.

GUSLANDII M. - - Relapsing ulcers and mucosal protecting agents. Lancet, 1981, 1, 387.

3. DRONFIELD M.W., BATCHELOR A . J . , LARKWOR- THY W., LANGMAN M.J.S. ^{- -} Controlled trial of maintenance cimetidine treatment in healed duodenal ulcer : short and long-term effects. Gut., 1979, 20, 526- 530.

6. HARVEY R.F., LANGMAN M.I.S. - - The late results of medical and surgical treatment for bleeding duodenal ulcer. Quarterly Journal o/ Medicine, 1970, 39, 539- 547.

A v a n t l'introduction de la fibroscopie gastrique, il

~tait impossible de savoir si un bulbe d~form# sur des cliches radiographiques ~tait associ~ ou non une ulceration active, et m ~ m e lorsqu'un ulcOre actif semblait visible dans un bulbe non d~Jormd, l'in- certitude demeurait quant ?~ la nature ulc~reuse de l'apparente discontinuit( de la muqueuse. Actuelle- ment, nous s o m m e s capables de d~cider si oui ou non, le traitement permettra de gu~rir l'ulcOre et apr~s gu~rison les taux de r~cidives p e u v e n t ~tre compares chez des patients soumis ~ diff~rents traite- ments m#dicaux.

La r~ps de l'endoscopie s'est rs163163 trbs utile dans l'~valuation des traitements. Par contre, aprbs avoir pos~ le diagnostic, sa valeur dans le traitement ordinaire est p r o b a b l e m e n t minime. Trois mddicaments possbdent une ef]icacitd d~montr~e dans la gus de l'ulcbre : les antagonistes des rdcepteurs H~ de l'histamine sans qu'il y ait des raisons de croire que la rs s y m p t o m a t i q u e ou la cicatrisation puissent diffdrer sous cim~tidine ou ranitidine, le bismuth ch$l# et la carbenoxolone et r~cemment Ie sucral[ate. L e taux de g u & i s o n s sous ces traitements varie de pays ~ pays. Cette observation reflbte p r o b a b l e m e n t le r~le de d e u x Jacteurs : le taux basal de gu(rison spontan~e chez les patients non trait~s, se pr~sentant dans difl~rents endroits et peut-~tre d'autres ]acteurs associ~s tels l'intensit~

d'un traitement antiacide simultan~. Lorsque les taux de gu~rison <~ naturelle ~> sont ~lev~s, la valeur des traitements s'en trouve d'autant plus diminu~e.

E n ce qui concerne les inhibiteurs des rs

H~ de l'histamine, il est actuellement clair que la dur~e ou l'intensitd du traitement initial ou la dur~e de l'intensit~ du traitement prs n'ont pas d'effet sur le r~sultat final [1, 3]. C'est fi peine sur- prenant c o m p t e tenu du role permissif de l'acide dans des circonstances o3 interviennent d'autres Jacteurs encore inconnus. On peut se permettre une analogie, bien qu'?t premiOre vue paradoxale, avec la relation entre frdquentation routi~re et accidents de la circulation. C e u x - c i rs de collisions entre v~hicules, qui ne p e u v e n t survenir que du fair de l'existence des routes !

L'abolition de la frs des routes inter- romprait les accidents et ceux-ci surviendraient nouveau dos la reprise du trafic.

Certains auteurs ont sugg~r~ que des cures courtes par ta carb~noxolone et le bismuth ch~l# pourraient affecter le c o m p o r t e m e n t de l'ulcOre aprbs l'arr~t du traitement [4, 5]. C'est possible mais surprenant : en effet, si la carb~noxolone d'une part agit c o m m e cytoprotecteur et le b i s m u t h ch~l~ d'autre part en formant une barri~re r~sistante ~ ia digestion pepti-

188 Volume 12 - N ~ 3 - 1982 Acta Endoscopica

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que acide, il n'y a aucune raison d'en attendre a u t o m a t i q u e m e n t un bdn6[ice prolongS.

Dbs lors, une lois la presence de l'ulc(ration [er- m e m e n t (tablie, ia r~ponse clinique peut ~tre appr6- ci(e fi partir des s y m p t ~ m e s . E n g~n6ral, les r(ponses s y m p t o m a t i q u e s et la cicatrisation vont de pair, mais en cas de r~ponses discortes, aucun tort n'a (t6 commis. N o u s n'avons pas d'argument pour croire q u ' u n patient devenu s y m p t o m a t i q u e mais dont l'ulcbre n'est pas gu~ri, va ~tre d~[avoris~ lors de l'arr~t du traitement. I n v e r s e m e n t , si les s y m p t ~ m e s persistent inchang~s, aucun clinicien sensd ne pour- suivra un traitement anti-ulc6reux sans reconsiddrer l'ensemble du probl~me. U n e attitude pragmatique paratt donc tout ~ [ait d~[endable.

E n cas d'hdmat~mbse et de mdlanea sur ulc~re duoddnal, la position est essentiellement la m~me.

A utrefois, l'ulcbre duodenal h~morragique ~tait trait( m~dicalement ~ l'exception des patients dont l'h6morragie dtait persistante et sdv~re en cours d'hospitalisation. A u R o y a u m e - U n i [6], les taux de rechutes, c'est-~-dire la r~cidive du saignement,

~taient bas, environ 20 % p o u r les cinq ann~es sui- vant l'h~morragie, et dans ces circonstances l'utilit~

d ' u n traitement antis~cr~toire apr~s hospitalisation semblait e x t r ~ m e m e n t douteuse. II est probable

qu'actuellement, la majorit~ des patients porteurs d' un ulcbre duodenal r~cent responsable d' une hdmorragie digestive seront soumis durant au m o i n s un ou d e u x mois, ?l un traitement intensi[ alors qu'au R o y a u m e - U n i , - - et nous n'avons pas de raison de croire que les circonstances soient di[](rentes ail- leurs - - le taux de rechutes aprbs un an est seule- m e n t de 7 % .

Il est licite de proposer un traitement continu chez les patients ages en raison de l'accroissement

~lev~ du risque de d(cbs par suite de complications ulc(reuses dans cette cat(gorie de malades et de la pleine justification d'une th~rapeutique prophylacti- que. L a r~ponse habituelle ? t c e problbme serait de r e c o m m a n d e r une intervention chirurgicale prdcoce et plus [r~quente, mais il y a de bonnes raisons de croire q u ' u n e teile option remplace, du m o i n s en pattie, une m o r t par h~morragie par une m o r t post- op~ratoire. T o u t traitement m ~ d i c a m e n t e u x entrat- nant un taux de mortalit~ de 1 % serait instantand- m e n t retir~ du march~, et pourtant le risque d'une chirurgie (Iective pour l'ulcbre duodenal c h e z les patients ~g6s, est sans doute au m o i n s de cet ordre.

Ce point rev~t une importance progressivement crois- sante au R o y a u m e - U n i et dans d'autres p a y s oft l'ulc~re tend ~ devenir une pathologie de la s~nes- cence.

Acta Endoscopica Volume 12 - N O 3 - 1982 189