Incompletely and completely healed duodenal ulcers' outcome in maintenance treatment: a double blind controlled study.

Abstract

SUMMARY A six month, double blind, controlled study was performed in 107 asymptomatic duodenal ulcer patients who, after short term cimetidine treatment, showed complete or incomplete endoscopic healing. Patients were stratified according to the type of healing and randomly allocated to cimetidine (200 mg at lunch, 400 mg at bedtime) or placebo. Endoscopic examinations were carried out after six months or when symptoms recurred. Eighty seven patients completed the maintenance trial. Of the 56 patients admitted to the study with complete healing, 30 were placed on cimetidine and 26 on placebo. Of the 31 patients admitted with incomplete healing, 15 were placed on cimetidine, and 16 on placebo. Results showed that, regardless of maintenance treatment, patients with incompletely healed ulcers had a higher ulcer crater recurrence rate, than patients with complete healing (71% vs 34%; p<0005). A significantly higher ulcer crater recurrence was observed in incompletely healed ulcer patients, even when cimetidine or placebo treatment groups were considered separately. Irrespective of the type of healing, ulcer crater recurrence was more frequent in placebo treated patients than in those treated with cimetidine (67% vs 29%; p<0.001). We conclude that, in order to prevent a high ulcer recurrence rate, maintenance treatment should start only after the assessment of a complete endoscopic healing of duodenal ulcers.The endoscopic definition of the healing of peptic ulcers lacks uniformity and this lack of universally accepted criteria could affect the scientific and clinical results of ulcer treatment.Ippoliti et al' found that, when ulcer healing was considered as disappearance of the ulcer crater, the ulcer healing rate, after four weeks' antacid treatment, was 86%. When on the other hand ulcer healing was considered as absence of both ulcer and erosions -that is, breaks in the mucosa without a fibrous base, the rate decreased to 52% Miyake et a12 described different stages of gastric ulcer healing. The third and fourth stages were called the palisade scar stage and the cobblestone stage, respectively. These are similar to the red and white scar stages described by Sakita.3 In previous studies-7 on the effects of various

Peptic ulcer recurrence during maintenance therapy with H 2 -receptor antagonist following first-line therapy with proton pump inhibitor

“…8 In a study investigating differences between S 1 -stage and S 2 -stage scars, using endoscopic ultrasonography (EUS) during H 2 RA administration for GU, an ulcer echo remained and the tissue under the regenerated epithelium had not healed completely in S 1 -stage patients. 17,18 This may cause the recurrences from S 1 -stage to be more frequent than those in patients with the S 2 -stage.…”

“…Ideally, healing should be evaluated by the S 2 -stage scar, because S 1 -stage scars with residual redness have been reported to show a higher recurrence rate than S 2 -stage scars with no redness. 7,8 However, there is a risk of mis-evaluation in the diagnosis of S 1 and S 2 stage scars that are based on the color of the regenerated mucosa.…”

Effect of Helicobacter pylori eradication on duodenal ulcer scar in patients with no clinical history of duodenal ulcer

“…Of the two scar stages, the red scar stage (S1) is the result of either recent ulcer healing or an incompletely healed ulcer, while the white scar stage (S2) describes a completely healed lesion. Patients with incompletely healed ulcers have a higher ulcer crater recurrence rate than those with complete healing 12 . Recurrences are more frequent in cases with a history of previous relapse, 13 , 14 and patients who readily heal on placebo therapy have a more benign form of ulcer disease, less disposed to recurrences, than those treated with antisecretory agents 15 .…”

“…Patients with incompletely healed ulcers have a higher ulcer crater recurrence rate than those with complete healing. 12 Recurrences are more frequent in cases with a history of previous relapse, 13,14 and patients who readily heal on placebo therapy have a more benign form of ulcer disease, less disposed to recurrences, than those treated with antisecretory agents. 15 Therefore, the white scar stage of duodenal ulcer in patients with no past history of duodenal ulcer carries with it the smallest probability of ulcer relapse.…”

The refractory ulcer

“…It has been shown that complete healing of a GU by hospital admission improves the prognosis of the patient over the subsequent 4 years [16]. Italian workers have shown that incomplete healing of DU adversely affects prognosis whether maintenance therapy is placebo or cimetidine [67]. Lance and Gazzard found that complete healing of duodenal ulcers did not influence prognosis [68].…”