28 , - 2557

HP and NSAID Negative PepticUlcer; How to Manage?

Review Article

morbidity mortality

2 Helicobacter pylori (HP)

nonsteroidal anti-inflammatory drugs (NSAIDs)

(idiopathic ulcer)

HP NSAIDs aspirin

HP NSAIDs

1 128

HP -NSAIDs negative GU 45.9 DU

29.6

HP 5-502-5

HP

HP HP

29HP and NSAID Negative Peptic Ulcer; How to Manage?

HP

Helicobacter pylori NSAIDs

HP

NSAIDs 72 6 (

60 HP) (

Class 3 American Society Anesthesiologists

risk classification) HP

5 ( 13.4 2.5 )7-10

10

HP NSAIDs

Helicobacter pylori NSAIDs

11

1. False negative HP test

HP

- HP

rapid urease test

Proton pump inhibitor ( 14 )

H2RA ( 7 ) Antibiotics ( 28 ) Bismuth-containing prepa-

ration ()

-

30 , - 2557

rapid urease test

- HP (

1)

- HP

608 9 HP 42

(6.9%) 18 (3%)

HP

HP

2. NSAIDs aspirin (surreptitious

use)

Cox-II inhibitor

1 H. pylori

Test Sensitivity/Specificity Comment

NoninvasiveSerology >80/>90 Not useful after treatment

Urea breath test >90/>90 Identified active infection

Less accurate if PPI use

Stool antigen >90/>90 Identified active infection

Monoclonal test

InvasiveRapid urease 80-95/95-100 Less accurate if PPI use

Histology 80-90/>95 Information of gastric mucosa

Culture -/100% Not widely available

Provide ATB testing

PCR Excellent Not widely available

Expensive

31HP and NSAID Negative Peptic Ulcer; How to Manage?

3.

8

- Nonspecific gastritis: bisphosphonate, potassium chloride

- Crystal deposition: iron, kayexalate

- Mimic of dysplasia: colchicine, chemotherapy

- SSRI: fluoxetine

- Acetaminophen

- Corticosteroid

- Clopidogrel

- Sirolimus, mycophenolate mofetil

- Spironolactone

4.

- Gastroduodenal Crohns disease Crohns disease

0.5-4

ileocolonic

207 4011

focally enhanced gastritis12 ( 1)13

HP stricture gastric outlet

obstruction

- Gastric lymphoma non-Hodgkins lymphoma

diffuse large B cell lymphoma

32 , - 2557

volcano crater polypoid

9514 im-

munohistochemistry lymphoma

5.

- Helicobacter heilmannii 1991 Heilmann

KL Helicobacter

pylori urease activity rapid

1 Endoscopic finding antrum Crohns disease

a: Redness, diffuse erosions, and granular changes

prednisolone. b: moderate infiltration of inflammatory cells c:

antrum prednisolone d:

inflammatory cell infiltration

33HP and NSAID Negative Peptic Ulcer; How to Manage?

urease test Helicobacter

pylori flagella 12

Helicobacter

pylori

- CMV

( antrum)

()

CMV

15

6. Systemic mastocytosis

histamine mast cell

16 histamine

pruritis, flushing, maculopapular rash

mast

cells

7. Gastric hypersecretion: Zollinger-Ellison syndrome (ZES)

Zollinger Ellison syndrome gastrin-secreting

tumor hypergastrinemia

34 , - 2557

reflux esophagitis

duodenal pancreatic enzyme steatorrhea

ZES multiple endocrine neoplasia syndrome

proton pump inhibitor ()

gastrin PPI gastrin

serum gastrin PPI

secretin test

8. Concomitant disease: cirrhosis, CKD, COPD

stress ulcer ( 2)

9. Radiation

brachytherapy

segment 2 3 1517

1 15.5 Gy

18

Vagus

35HP and NSAID Negative Peptic Ulcer; How to Manage?

10. Camerons ulcer

hiatal hernia

hiatal hernia 5 .

10-20

11. True idiopathic ulcer

true idiopathic ulcer

gastric function test

2 stress ulcer

36 , - 2557

gastrin gastric emptying time 19

gastrin PPI

PPI

HP NSAIDs

-

- Helicobacter pylori

-

body antrum

- Helicobacter pylori PPIs antibiot-

ics

- NSAID (

salicylate)

- serum gastrin

proton pump inhibitor Helicobacter pylori

randomized controlled trial

Helicobactor pylori

proton pump inhibitor

HP PPI

20

37HP and NSAID Negative Peptic Ulcer; How to Manage?

HP NSAID HP

NSAIDs

PPI

1. Goenka MK, Majumder S, Sethy PK, Chakraborty M. Helicobacter pylori nega-tive, non-steroidal anti-inflammatory drug-negative peptic ulcers in India. In-dian J Gastroenterol. 2011;30:33-7.

2. Ciociola AA, McSorley DJ, Turner K, Sykes D, Palmer JB. Helicobacter pyloriinfection rates in duodenal ulcer patients in the United States may be lowerthan previously estimated. Am J Gastroenterol. 1999;94:1834-40.

3. Jyotheeswaran S, Shah AN, Jin HO, Potter GD, Ona FV, Chey WY. Prevalence ofHelicobacter pylori in peptic ulcer patients in greater Rochester, NY: is empiri-cal triple therapy justified? Am J Gastroenterol. 1998;93:574-8.

4. Aoyama N, Shinoda Y, Matsushima Y, Shirasaka D, Kinoshita Y, Kasuga M, etal. Helicobacter pylori-negative peptic ulcer in Japan: which contributes mostto peptic ulcer development, Helicobacter pylori, NSAIDS or stress? JGastroenterol. 2000;35 Suppl 12:33-7.

5. Arroyo MT, Forne M, de Argila CM, Feu F, Arenas J, de la Vega J, et al. Theprevalence of peptic ulcer not related to Helicobacter pylori or non-steroidalanti-inflammatory drug use is negligible in southern Europe. Helicobacter.2004;9:249-54.

6. Hung LC, Ching JY, Sung JJ, To KF, Hui AJ, Wong VW, et al. Long-termoutcome of Helicobacter pylori-negative idiopathic bleeding ulcers: a prospec-

38 , - 2557

tive cohort study. Gastroenterology. 2005;128:1845-50.7. Alcantara M, Rodriguez R, Potenciano JL, Carrobles JL, Munoz C, Gomez R.

Endoscopic and bioptic findings in the upper gastrointestinal tract in patientswith Crohns disease. Endoscopy. 1993;25:282-6.

8. Parfitt JR, Driman DK. Pathological effects of drugs on the gastrointestinal tract:a review. Hum Pathol. 2007;38:527-36.

9. Pietroiusti A, Forlini A, Magrini A, Galante A, Bergamaschi A. Isolated H. pyloriduodenal colonization and idiopathic duodenal ulcers. Am J Gastroenterol.2008;103:55-61.

10. Wong GL, Wong VW, Chan Y, Ching JY, Au K, Hui AJ, et al. High incidence ofmortality and recurrent bleeding in patients with Helicobacter pylori-negativeidiopathic bleeding ulcers. Gastroenterology. 2009;137:525-31.

11. Oberhuber G, Hirsch M, Stolte M. High incidence of upper gastrointestinal tractinvolvement in Crohns disease. Virchows Arch. 1998;432:49-52.

12. Mottet C, Juillerat P, Pittet V, Gonvers JJ, Michetti P, Vader JP, et al. Uppergastrointestinal Crohns disease. Digestion. 2007;76:136-40.

13. Umehara Y, Kudo M, Kawasaki M. Crohns disease with gastroduodenal mucosalesions that are similar to the lesions caused by ulcerative colitis. InflammBowel Dis. 2009;15:646-8.

14. Fischbach W, Dragosics B, Kolve-Goebeler ME, Ohmann C, Greiner A, Yang Q,et al. Primary gastric B-cell lymphoma: results of a prospective multicenterstudy. The German-Austrian Gastrointestinal Lymphoma Study Group. Gastro-enterology. 2000;119:1191-202.

15. Lin WR, Su MY, Hsu CM, Ho YP, Ngan KW, Chiu CT, et al. Clinical and endo-scopic features for alimentary tract cytomegalovirus disease: report of 20 caseswith gastrointestinal cytomegalovirus disease. Chang Gung Med J. 2005;28:476-84.

16. Cherner JA, Jensen RT, Dubois A, ODorisio TM, Gardner JD, Metcalfe DD.Gastrointestinal dysfunction in systemic mastocytosis. A prospective study.Gastroenterology. 1988;95:657-67.

39HP and NSAID Negative Peptic Ulcer; How to Manage?

17. Streitparth F, Pech M, Bohmig M, Ruehl R, Peters N, Wieners G, et al. In vivoassessment of the gastric mucosal tolerance dose after single fraction, smallvolume irradiation of liver malignancies by computed tomography-guided, high-dose-rate brachytherapy. Int J Radiat Oncol Biol Phys. 2006;65:1479-86.

18. Gompertz RH, Michalowski AS, Man WK, Spencer J, Baron JH. Duodenal ulcer:a model of impaired mucosal defence. Gut. 1992;33:1044-9.

19. Kamada T, Haruma K, Kusunoki H, Miyamoto M, Ito M, Kitadai Y, et al. Signifi-cance of an exaggerated meal-stimulated gastrin response in pathogenesis ofHelicobacter pylori-negative duodenal ulcer. Dig Dis Sci. 2003;48:644-51.

20. Bytzer P, Teglbjaerg PS. Helicobacter pylori-negative duodenal ulcers: preva-lence, clinical characteristics, and prognosis-results from a randomized trialwith 2-year follow-up. Am J Gastroenterol. 2001;96:1409-16.

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