Gisbert J P, Boixeda D, Martín De Argila C, Alvarez Baleriola I, Abraira V, García Plaza A
Dept. of Gastroenterology, Hospital Ramon y Cajal, University of Alcalá de Henares, Madrid, Spain.
Scand J Gastroenterol. 1997 Jul;32(7):643-50. doi: 10.3109/00365529708996512.
Our aims were 1) to study the influence of several factors (age, sex, smoking, previous ulcer disease, ulcer size, chronic gastritis, serum gastrin and pepsinogen I levels, therapy regimen and, especially, eradication of Helicobacter pylori) on duodenal ulcer healing; 2) to evaluate the frequency of duodenal ulcer healing failure despite eradication of H. pylori, to study why this failure occurs, and to verify its evolution without antisecretory therapy; and 3) to confirm whether a week's prescription of omeprazole is sufficient to obtain ulcer healing.
Three-hundred and eight patients (mean age, 45 +/- 13 years; 71% males) with duodenal ulcer and H. pylori infection were studied prospectively. Biopsy specimens were obtained at initial endoscopy, and serum gastrin and pepsinogen I levels were measured. A repeat endoscopy (with biopsies) was performed 1 month after eradication therapy had been completed, and a 13C-urea breath test was also carried out. Three eradication therapies were used: omeprazole plus amoxycillin for 2 weeks (OA group, n = 61); 'classic' triple therapy (with bismuth; CTT group, n = 65); and 'new' triple therapies for 1 week (NTT group, n = 182): omeprazole plus two of the following antibiotics: clarithromycin, metronidazole, and amoxycillin. When the ulcer did not heal despite successful H. pylori eradication, antacids were prescribed on an as-needed basis, and endoscopy was repeated 1 month later (2nd control endoscopy). If the ulcer was still present, the acid output (basal and pentagastrin-stimulated) was measured, a secretin test was performed, and a final endoscopy (3rd control endoscopy) was carried out after an additional month. The statistical method used was multiple logistic regression.
Overall eradication was achieved in 69% (n = 212) of the patients, and ulcer healing in 76% (n = 233): 57% in the OA group, 80% in the CTT group, and 81% in the NTT group (P < 0.01 when comparing the OA group with the others). Ulcer healing was achieved in 90% of H. pylori-eradicated patients and in only 45% of patients with eradication therapy failure (P < 0.001). Similar results were obtained when only patients treated with NTT were considered: ulcer healing in 90% of patients with the organisms eradicated. Eradication of H. pylori (odds ratio (OR), 11.8; 95% confidence interval (CI), 6.3-22) and sex (OR, 2.5; 95% CI, 1.2-5.1) were the only variables that correlated with ulcer healing in the multivariate analysis. The ulcer persisted despite successful eradication of H. pylori in 22 patients. The duodenal ulcer had healed spontaneously in 73% of these patients at the 2nd control endoscopy. Finally, by the 3rd control endoscopy, only three patients still had duodenal ulcer. Therefore, ulcer healing was finally achieved in 98.1% (95-99%) of patients in whom H. pylori was eradicated. Gastrin, pepsinogen I, acid output, and the secretin test had normal values in all patients.
Eradication of H. pylori favours ulcer healing, which is achieved in most patients in whom the organism is eradicated. Just 1 week of omeprazole therapy (that is, the antibiotic administration period in the new triple therapies) is enough to obtain a high ulcer healing rate. Most duodenal ulcers that do not heal initially despite H. pylori eradication will ultimately do so after several weeks without additional therapy.
我们的目的是：1）研究几个因素（年龄、性别、吸烟、既往溃疡病、溃疡大小、慢性胃炎、血清胃泌素和胃蛋白酶原I水平、治疗方案，尤其是幽门螺杆菌根除情况）对十二指肠溃疡愈合的影响；2）评估尽管根除了幽门螺杆菌但十二指肠溃疡愈合失败的频率，研究这种失败发生的原因，并在不进行抗分泌治疗的情况下验证其演变情况；3）确认奥美拉唑一周的疗程是否足以实现溃疡愈合。
前瞻性研究了308例患有十二指肠溃疡和幽门螺杆菌感染的患者（平均年龄45±13岁；71%为男性）。在初次内镜检查时获取活检标本，并测量血清胃泌素和胃蛋白酶原I水平。在根除治疗完成后1个月进行重复内镜检查（取活检），并进行13C-尿素呼气试验。使用了三种根除疗法：奥美拉唑加阿莫西林治疗2周（OA组，n = 61）；“经典”三联疗法（含铋剂；CTT组，n = 65）；以及1周的“新型”三联疗法（NTT组，n = 182）：奥美拉唑加以下两种抗生素：克拉霉素、甲硝唑和阿莫西林。当尽管成功根除幽门螺杆菌但溃疡仍未愈合时，按需开具抗酸剂，并在1个月后重复内镜检查（第二次对照内镜检查）。如果溃疡仍然存在，则测量胃酸分泌（基础胃酸分泌和五肽胃泌素刺激后的胃酸分泌），进行促胰液素试验，并在再过1个月后进行最后一次内镜检查（第三次对照内镜检查）。所使用的统计方法是多元逻辑回归。
69%（n = 212）的患者实现了总体根除，76%（n = 233）的患者溃疡愈合：OA组为57%，CTT组为80%，NTT组为81%（OA组与其他组比较时P < 0.01）。在根除幽门螺杆菌的患者中，90%实现了溃疡愈合，而根除治疗失败的患者中只有45%实现了溃疡愈合（P < 0.001）。仅考虑接受NTT治疗的患者时也获得了类似结果：在根除幽门螺杆菌的患者中，90%实现了溃疡愈合。在多变量分析中，根除幽门螺杆菌（优势比（OR），11.8；95%置信区间（CI），6.3 - 22）和性别（OR，2.5；95% CI，1.2 - 5.1）是与溃疡愈合相关的仅有的变量。22例患者尽管成功根除了幽门螺杆菌，但溃疡仍然存在。在第二次对照内镜检查时，这些患者中有73%的十二指肠溃疡已自发愈合。最后，到第三次对照内镜检查时，只有3例患者仍有十二指肠溃疡。因此，在根除幽门螺杆菌的患者中，最终98.1%（95 - 99%）的患者实现了溃疡愈合。所有患者的胃泌素、胃蛋白酶原I、胃酸分泌和促胰液素试验结果均正常。
根除幽门螺杆菌有利于溃疡愈合，在大多数根除该菌的患者中可实现溃疡愈合。仅1周的奥美拉唑治疗（即新型三联疗法中的抗生素给药期）就足以获得较高的溃疡愈合率。大多数尽管根除了幽门螺杆菌但最初未愈合的十二指肠溃疡在数周内无需额外治疗最终也会愈合。
