Natural Supplements for Gastric Ulcer
Peptic ulcer disease is a chronic illness manifested by recurrent ulcerations in the stomach and proximal duodenum. Acid and pepsin are thought to be crucial to ulcer development, but it is now recognized that the great majority of peptic ulcers are directly related to infection with Helicobacter pylori or nonsteroidal anti-inflammatory drug (NSAID) use.12 Gastritis is acute or chronic inflammation of the gastric mucosa and has various etiologies. Dyspepsia is continuous or recurrent upper abdominal pain or discomfort with or without associated symptoms (nausea, bloating, regurgitation, etc.).34 Dyspepsia may be caused by a number of diseases or may be functional.
Complications of peptic ulcer disease are now much less common than 20 years ago due to improved medical management (see Peptic Ulcer, below), but perforations still imply a mortality of approximately 10 (higher in older patients). The well-recognised risk factors for developing a perforation are long-term non-steroidal anti-inflammatory drug (NSAID) use, and Helicobacter pylori infection. Once the perforation has been successfully dealt with, the peptic ulcer must be treated with full medical management as described below. This will include eradication of H. pylori if present, stopping NSAIDs as appropriate (or switching to alternative analgesia), and a healing course of anti-secretory medication.
Although NSAIDs should be stopped in patients with peptic ulcer disease whenever possible, misoprostol may prevent ulcer formation in those on concurrant NSAID therapy. Misoprostol is a prostaglandin analogue that may act by increasing mucous and bicarbonate production and by increasing mucosal blood flow. If H. pylori infection is diagnosed in the presence of peptic ulcer disease, eradication is clearly indicated. 1 15 Multiple regimens have been proposed and studied mainly using combinations of bismuth subsalicylate, amoxicillin, tetracycline, metronidazole, clarithromycin, an H 2RA (mainly ranitidine), and a PPI (mainly Patients generally do not present to the emergency department with a definitive diagnosis of peptic ulcer disease but, rather, with a symptom, such as epigastric pain. If appropriate history, physical examination, and laboratory evaluation result in a physician's impression of possible peptic ulcer disease or dyspepsia, the physician is left with three main options...
The management of peptic ulcer disease has changed dramatically in the last 20 years as the aetiology of peptic ulceration has become more clearly understood, and more powerful and effective medical treatment has evolved. At the same time there has been a dramatic decrease in both elective and emergency surgery for peptic ulceration. Aetiological factors in peptic ulceration include H. pylori infection, NSAID ingestion, smoking, renal failure, liver disease, and ZollingerEllison (ZE) syndrome. H. pylori is by far the most important, and adequate management of H. pylori is the mainstay of modern ulcer therapy. H. pylori is a spiral, gram-negative bacteria which is spread by direct contact, and infects up to 60 of the population, though only 5-10 of those infected develop ulceration. H. pylori causes increased gastrin levels, a rise in gastric acid production, and also has a direct effect on gastric and duodenal mucosa. NSAIDs have both a localised and systemic effect on gastric and...
Peptic ulcer disease refers to the mucosal lesion in the stomach (gastric ulcer, GU) or the duodenum (duodenal ulcer, DU) where acid and the enzyme pepsin contribute to tissue damage that extends into the submucosa. It is thought to occur when there is an imbalance between the protective factors and the aggressive factors in the gastric milieu. The stomach relies on the different layers of mucosal defense (e.g., mucus bicarbonate layer, cell membrane) to protect itself. If this is breached and epithelial cell injury occurs, then repair may occur by cellular restitution, replication, or formation of granulation tissue. A primary defect in these defense and repair mechanisms rarely causes ulcers. The hypothesis underlying the pathogenesis of peptic ulcer disease is that acid and pepsin are able to cause tissue damage if the normal defenses and repair mechanisms of the stomach are altered by H. pylori infection or the use of non-steroidal anti-inflammatory drugs (NSAIDs).
Organisms multiply only when the conditions are beneficial, and when not multiplying, they concentrate on survival of environmental stress. Many bacteria that harm humans survive for most of the period of infection in a low-growth state. This book addresses the basic scientific aspects of microbial dormancy and low-growth states, and places them in the context of human medicine. The book introduces basic scientific aspects of bacterial growth, non-growth, culturability, and viability. Later chapters cover the crucial relationship between low-growth states and survival of stress, the survival of the immune response, and interbacterial signalling. This is followed by chapters on aspects that are of direct importance to medicine, namely antibiotic resistance arising in stationary phase, biofilms, tuberculosis, and the bacteria, which cause gastric ulcers.
Autoantibodies are readily detected by IIF with sections of rodent stomach (mucosa) as tissue substrate. The pattern of staining resembles that seen with mitochondrial antibodies therefore, a control test on kidney should also be performed. Parietal cell antibodies are found in 90 or more of patients with pernicious anemia. Recently, the autoantigen has been identified as the a and 3 subunits of gastric H+,K+-ATPase. An ELISA using this enzyme and a western blotting technique using gastric extracts have been developed. These antibodies are also present in a number of other conditions, such as chronic thyroiditis (33 ), Sjogren's sicca syndrome (15 ), atrophic gastritis (60 ), gastric ulcer (22 ), etc. The antibodies are also found in the normal population, with an incidence that varies according to age and sex i.e. from 2 in subjects under 20 years old to 16 in subjects over 60 years old. They are more frequent in women than in men.
Left upper quadrant pain can be secondary to pancreatitis, peptic ulcer disease, subphrenic abscess, jejunal diverticulitis, splenic rupture or infarction, and left lower lobe pneumonia. Splenic infarction is commonly associated with sickle cell disease. This diagnosis does not always require surgical resection. Treatment should be considered if the patient exhibits clinical signs of infection such as a leukocytosis or has elevated temperatures. Refractory pain is also an indication for surgical resection.
Zollinger-Ellison syndrome was first described by Zollinger and Ellison as a condition caused by non-insulin-secreting tumors of the pancreas which lead to the development of an ulcerogenic state.10 These tumors were eventually found to elaborate gastrin. Gastrinomas are rare tumors that arise from neuroendocrine cells which produce a unique clinical picture (Table 9-5). The majority of gastrinomas are sporadic. Approximately 25 percent of gastrinomas are associated with the multiple endocrine neoplasia type I (MEN I) syndrome. The presence of hypercalcemia associated with peptic ulcer disease should prompt a workup for ZES. The diagnosis is made by measuring a serum gastrin level. Patients with a gastrinoma generally have levels greater than 1000 pg mL. In cases where the gastrin is not clearly elevated, but suspicion is high, one can use a secretin stimulation test. Secretin is administered intravenously (2 U kg) after obtaining a baseline gastrin level. Gastrin levels are...
A 45-year-old woman with a history of peptic ulcer disease reports six days of persistent vomiting. On examination she has a blood pressure of 100 60 mmHg and looks dehydrated. Her blood results are as follows sodium 140 mmol l, potassium 2.2 mmol l, chloride 86 mmol l, bicarbonate 40 mmol l, urea
Is it bloody, bilious or nonbilious, feculent or posttussive Hematemesis is seen with gastritis, peptic ulcer disease, gastric and esophageal tumors, and Mallory-Weiss tears. Nonbilious emesis occurs with gastric outlet obstruction, as in patients with pyloric strictures secondary to ulcer disease or infants with pyloric stenosis. Second, determine what symptoms accompany the vomiting. Is the patient febrile Fever could point toward an infectious or inflammatory source, or it could represent a toxicologic cause, such as salicylate intoxication. Is there associated abdominal pain, back pain, headache, or chest pain that may point to a specific cause Pancreatitis, cholecystitis, peptic ulcer disease, appendicitis, and pelvic inflammatory disease typically cause abdominal pain. Back pain usually accompanies aortic dissections, rupturing aortic aneurysms, pyelonephritis, and renal colic. Vomiting is one of the signs of increased intracranial or intraocular...
The most obvious applications of PK PD are to describe the time course of a drug effect or clinical response such as changes in blood pressure or pain. However, many clinical responses are more closely related to the cumulative effects of the drug. For example, the healing of a peptic ulcer is the consequence of cumulative inhibition of gastric acid secretion and increase in pH allowing tissue repair. The time course of changes after each dose may be important for acute symptomatic relief of pain, but it is the cumulative effect that leads to the healing response. Another example would be the use of a diuretic to treat acute pulmonary edema. The clinical benefit arises from the cumulative loss of fluid and is not determined by the effect of the drug at particular times after the dose.
Rates after eradication of H. pylori from the stomach of peptic ulcer patients has been reported (Marshall et al., 1988 Hantschel et al., 1993). It has been established that H. pylori infection is a major cause of chronic gastritis and peptic ulcer disease. H. pylori was designated a first class definite carcinogen for stomach cancer in 1994 following epidemiological investigation by the International Agency for Research on Cancer (IARC, 1994), a subordinate organization of the World Health Organization. Furthermore, association of primary malignant gastric lymphoma with H. pylori has been reported in a large-scale cohort study (Parsonnet et al., 1994).
A group of Finnish investigators conducted a retrospective chart review.2 The typical eligibility criteria for clinical trials of patients with gastric ulcer were applied to 400 patients hospitalized with the diagnosis of gastric ulcer. Only 29 of the patients met the eligibility criteria and almost all deaths and serious complications such as gastric bleeding, perforation and stenosis during the first five to seven years occurred among those patients who would have been ineligible. Clearly, the testing of H - blockers or other compounds for the prevention of long-term complications of gastric ulcer in low-risk patients should not be generalized to the entire ulcer population.
Resuscitation of the patient is the priority, with airway control and provision of oxygen plus large bore intravenous access. Blood should be taken for estimation of haemoglobin, urea, electrolytes, liver function and coagulation profile. Blood should be cross-matched and blood, and products given as required. Urinary and nasogastric catheters are helpful and arterial blood gas analysis will also help to guide the resuscitative effort. The history is important and evidence should be sought of previous GI bleeding, peptic ulcer or inflammatory bowel disease, liver disease, non-steroidal or warfarin usage. The abdomen and anorectum must be carefully examined and bedside examination of the anal canal and rectum are mandatory. If there is any suspicion of an upper GI source, this should be ruled out by upper GI endoscopy.
Figure 10.2.1 shows a case of GIST in which no abnormalities were found by upper or lower gastrointestinal endoscopy performed to investigate repeated melena. The diagnosis was made on the basis of biopsy specimens obtained by double-balloon endoscopy 4 . The endoscopy revealed a rather sharply protruding submucosal tumor with a bleeding ulcer on the top (Fig. 10.2.1a) a similar finding was shown by selective, contrast-enhanced radiography (Fig. 10.2.1b). After a histologically confirmed diagnosis, partial resection of the small intestine was performed (Fig. 10.2.1c).
Patients receiving anticoagulant treatment require adjustments in their anticoagulation when undergoing different types of non-cardiac surgery or diagnostic procedures. This most commonly arises when patients undergo dental procedures, but anticoagulant adjustment is also required for ophthalmic and minor or major surgical procedures, either on an elective or emergency basis. Patients may need to undergo interventional cardiac procedures such cardiac catheterisation, coronary angio-plasty, and the implantation of pacemakers or defibrillators, which also necessitate alteration in anticoagulation. Adjustment is also needed in the event of conditions such as cerebral haemorrhage and certain gastrointestinal disorders such as bleeding ulcer. Randomised studies are not available for most of these situations 8 and there are only a few prospective observational studiesw9 to guide management. Much of the available information comes from retrospective analyses, and opinions differ over what is...
Patients with acute biliary colic display a wide range of symptoms. Location, radiation, and duration of pain are all poor discriminators of gallbladder disease. There is overlap of signs and symptoms with peptic ulcer disease, gastritis, esophageal reflux, and nonspecific dyspepsia. In addition, it has been difficult to determine which symptoms are attributable to biliary tract disease.7,8 RUQ pain is a common symptom in patients with and without gallstones.39 Up to 25 percent of postcholecystectomy patients may experience RUQ pain of unknown cause.
The GSRS is a clinical symptom rating scale originally designed for patients with irritable bowel syndrome and peptic ulcer disease 122 . It has subsequently been evaluated in patients with GERD 105, 123 . GSRS for use with GERD patients contains 15 items, each assessed on a 1-point to 7-point scale, with 7 representing extreme discomfort. The items combine into five syndromes labeled reflux, abdominal pain, indigestion, diarrhea, and constipation. Mean scores are calculated from the items in each syndrome. The measure may be administered as a self-report or by an interviewer. The GSRS has been used in UK, Scandinavian, and US populations. It demonstrates acceptable reliability, both internal consistency and stability, evidence of construct and discriminative validity, as well as responsiveness to change. A copy of the US version of the GSRS is included in the article by Revicki and colleagues 105 . 122. Svedlund J, Sj din I, Dotevall G (1988) GSRS - a clinical rating scale for...
Bleeding Ulcers Nonoperative Therapies 151 Incidence and Symptoms 151 Nonoperative Treatment Methods 151 Indications for Endoscopic Treatment 151 Bleeding Ulcers Forrest Classification 152 Bleeding Ulcers Pharmacological Therapy and Injection Techniques 153 Pharmacological Therapy of Bleeding Ulcers 153 Endoscopic Techniques 153 Injection Therapy . . . 153 Bleeding Ulcers Hemoclip Application and Thermal Methods 154 Hemoclip Application 154 Thermal Methods 154 Bleeding Ulcers Management after Primary Hemostasis and in Special Cases . . . 155
PEPTIC ULCER DISEASE Peptic ulcer disease, including gastric, duodenal, and stomal ulcers, remains the most common etiology for upper GI hemorrhage, encompassing approximately 60 percent of all cases.2 Duodenal ulcers, approximately 29 percent of the total, will rebleed in approximately 10 percent of cases, usually within 24 to 48 h. Gastric ulcers, approximately 16 percent of all cases, are more likely to rebleed. Stomal ulcers are uncommon (less than 5 percent of all upper GI bleeds) and are present in only one-third of bleeding patients with a history of prior peptic ulcer surgery.
A remarkable change in the epidemiology of subphrenic and subhepatic abscesses has occurred over the past several decades. In the past, the most common causes included perforations of anterior gastric or duodenal ulcers and rupture of a gangrenous appendix. Today, 6071 of such abscesses are postoperative and are particularly frequent following gastric and biliary tract operations and colonic surgery. 1-3 Many of the cases of postoperative abscesses are secondary to anastomotic leaks.4 More prompt diagnosis currently in conditions such as peptic ulcer and appendicitis, leading to earlier surgical intervention, results in an increasing proportion of postoperative abscesses. The bacterial flora generally consist of multiple strains of aerobic and anaerobic organisms. The aerobes include particularly Escherichia coli, Streptococcus, Klebsiella, and Proteus the anaerobes, Bac-teroides and cocci.2
Common substrates of all OCTs include low-molecular-weight relatively hydrophilic organic cations such as the prototypical cation TEA, the neurotoxin MPP+, and the endogenous compound N-methylnicotinamide (NMN).18'20'32 Several clinically important drugs have been shown to interact with all of the OCTs, including the antidiabetic drug metformin,18 33 and the peptic ulcer drug famotidine,34 demonstrating the broad potential for influence of OCTs on drug disposition and drug action. Figure 2.3 shows the structures of several compounds that interact with OCTs. Table 2.1 lists known substrates and inhibitors of human OCTs.18'20'30'32-38
Bleeding from the hepatic artery is clearly shown in the following case history. A 70-year-old man was examined because of a 1 -month history of colicky right upper quadrant pain. His past medical history included acute rheumatic fever at the age of 5 and an episode of acute staphylococcal endocarditis at the age of 56. Oral cholecystography revealed moderate opacification of the gallbladder, and the hepatic angle, flank fat, and psoas muscle were clearly visualized (Fig. 8-99a) at this time. However, 24 hours later, the patient's colicky right upper quadrant pain increased suddenly, with abdominal distention. Initial diagnostic considerations included acute cholecystitis, acute pancreatitis, and penetrating peptic ulcer. An abdominal radiograph now showed a density throughout the right abdomen, with loss of the
As sepsis is associated with multiple system organ failure, there are other supportive therapies used to treat these patients, which do not directly relate to the sepsis itself. Deep vein thrombosis (DVT) prophylaxis, nutritional support, and stress peptic ulcer prophylaxis are important adjuvant therapies. Nutritional support, especially enteral (via nasogastric tube) is important in supporting the hypercatabolic critically ill patient, preventing stress ulcers, and maintaining gut mucosal integrity. Tight glucose has also been shown to improve outcome.
Acute gastrointestinal complications may or may not be related to the underlying malignancy. In patients with cancer, even gastric cancer, the major causes of gastrointestinal bleeding are still hemorrhagic gastritis and peptic ulcer disease. Intraarterial hepatic chemotherapy infusions have been associated with gastrointestinal bleeding, especially from the duodenum. Chemotherapy or radiotherapy can cause vomiting, resulting in Mallory-Weiss tears or reflux esophagitis.
Forms in adenocarcinoma was significantly greater than in benign peptic ulcers. In Greece, H. pylori was found in antral biopsy samples as coccoids and spirals (18). Coccoid bacteria are relatively common in the duodenal bulb (38). Janas et al. (25) found coccoid forms were present only above strongly damaged epithelial cells. Coccoids can bind to the gastric mucosa (42).
To illustrate how highly selected the cohort of eligible trial patients are, Kaariainen and colleagues11 analysed 397 consecutively hospitalised cases of gastric ulcer to determine what proportion would be eligible for participation in drug trials and how the eligibility criteria affected generalisability. When the commonly used exclusion criteria were applied, 282 patients (71 ) met at least one of them. Several patients had two or more reasons for exclusion. The most troubling findings came from an extended follow up of all 397 patients. Major complications of gastric ulcer bleeding, perforation, gastric retention, and deaths occurred in 71 patients, and only two of those were observed in the 115 patients who met the typical eligibility criteria for trials of gastric ulcer. Patients with the worst prognosis would have been excluded. The authors concluded when many patients are excluded, the applicability of the results to the whole material is questionable.
The majority of patients with peptic ulcers are infected with H. pylori (95-100 for DU 75-85 for GU). Although only a small proportion of all H. pylori-positive individuals are found to have peptic ulcer disease (1-6 ), this is a four- to tenfold increase of the number who are H. pylori-negative. The causal relationship between H. pylori infection and ulcers is further supported by the reduction of ulcer recurrence after H. pylori eradication. It is generally accepted, however, that other factors contribute to the pathogenesis of ulcers. It is known that smoking reduces healing and is also associated with peptic ulcer disease. Variations in bacterial strain virulence and host immune response may also be determinants of pathogenicity. Infection with H. pylori results in a chronic, active gastritis in the antrum or the entire stomach. Peptic ulcers have long been associated with a diffuse antral gastritis. Gastritis is not a predominant feature in other forms of peptic ulcer (e.g.,...
Duodenal ulcers are two to three times more common than gastric ulcers. Gastric ulcers are most frequent among those aged 40-70 years, whereas duodenal ulcers are most commonly seen between the age of 25 and 55 years. Thus, complications in gastric ulcers tend to be more severe because they tend to affect older individuals. Ulcer rates are declining rapidly for younger men and increasing for older individuals. Acid secretion patterns differ with the location of the ulcer. Duodenal ulcers are associated with high-acid secretion while proximal gastric ulcers are associated with a low-acid output. Distal gastric ulcers can have a normal- or high-acid output. The difference in acid output is a reflection of the effects of inflammation on the underlying cell types. Inflammation of the antrum and the body is much more pronounced in gastric ulcer than in duodenal ulcer. In addition, there is usually a progression of inflammation in gastric ulcers. As a result, this could
Early transgenic farm animal research was inspired by the dramatic growth of transgenic mice that expressed a growth hormone (GH) transgene. 1 A number of transgenic pigs and sheep were subsequently produced with human, bovine, rat, porcine, or ovine GH under the control of several gene promoters. 2 Although pigs expressing GH transgenes grew faster, utilized feed more efficiently, and were much leaner than their nontrans-genic siblings, they were not larger and exhibited several notable health problems, which included lameness, susceptibility to stress, gastric ulcers, and reproductive prob-lems. 2 The GH transgenic lambs did not grow faster or utilize feed more efficiently than control lambs, but they were much leaner and had serious health problems. 2
C NSAID-induced bleeding ulcer of the ileum in a 76-year-old woman taking oral diclofenac sodium d Circumferential stenosis of the ileum in a patient who had been taking oral NSAIDs for a long time c NSAID-induced bleeding ulcer of the ileum in a 76-year-old woman taking oral diclofenac sodium d Circumferential stenosis of the ileum in a patient who had been taking oral NSAIDs for a long time
The characteristic plain film findings are demonstration of a circumscribed collection of gas-containing intestinal loops high in the abdomen medial and posterior to the stomach, associated with mechanical small bowel obstruction (Figs. 16-26 and 16-27). Distinction from other conditions that can present with gas in the lesser sac (e.g., perforated peptic ulcer or abscess) is possible by identification of the presence of a mucosal pattern and fluid levels within the herniated bowel. The fluid levels do not conform precisely to the anatomic recesses of the lesser omental cavity. If the colon is involved in the hernia, there may be a single air-fluid level, but several fluid levels may be present if a segment of small intestine is involved. The stomach is displaced to the left and anteriorly. Dilated small bowel loops generally de-
Gallstone pain can be very similar to that of renal colic and should generally be considered in all patients with any right upper quadrant abdominal tenderness. Unlike the symptoms of renal colic, biliary colic symptoms are often associated with oral intake, last for several hours before remitting, and include vomiting. Pancreatitis is suggested by left upper quadrant or midepigastric pain, especially in the presence of risk factors (e.g., alcohol consumption or cholelithiasis). A perforated peptic ulcer may present with severe pain in the midepigastrum or either upper quadrant. However, these patients have marked tenderness on examination and develop peritoneal signs over time. Appendicitis shares the unilateral presentation with renal colic, but the subacute prodrome usually excludes urolithiasis. Ventral hernias should also be considered in the differential diagnosis and sought on physical examination. Diverticulitis usually causes pain in lower quadrants, more commonly the left,...
NSAIDs' enzyme-inhibitor effect also increases your risk of bleeding and stomach ulcers. If you want to take an OTC NSAID on a regular basis, discuss it with your doctor first. Side effects of increased bleeding and stomach ulcers can make NSAIDs dangerous if you have any of the following issues Congestive heart failure Gastroesophageal reflux disease (GERD) Liver disease Renal (kidney) disease Stomach ulcers NSAIDs have a large list of potential side effects besides the more serious problems of bleeding and stomach ulcers. Allergic reactions are common. In addition, you may experience any of the following
Various methods of endoscopic hemostasis have been developed for successful treatment of a variety of bleeding lesions in the gastrointestinal tract, including a peptic ulcer in the stomach and duodenum and angiodysplasia and diverticular hemorrhage in the large intestine. These successful endoscopic treatments obviate surgery in many patients, and endo-scopic hemostasis is one of the great achievements of therapeutic endoscopy. A variety of hemostatic techniques, including injection of ethanol or hypertonic saline, cauterization with an argon plasma coagulator (APC) or a heat probe, and hemostasis with a clip have been developed and put to practical use. They have led to the establishment of therapeutics involving the selection, indications, and techniques of treatments based on the pathological condition of the bleeding lesions. Although the principle of insertion differs between the double-balloon endoscope and conventional endoscopes, all hemostatic techniques used for...
In addition to the problems directly related to episodes of acute alcohol intoxication, there is widespread recognition of the harm caused by chronic excessive drinking, commonly referred to as alcoholism. At sufficient doses, the daily or frequent drinker may experience increased tolerance and, eventually, physiological dependence and withdrawal symptoms. Prolonged heavy drinking is implicated in a number of serious and potentially fatal health problems, including cirrhosis, pancreatitis, peptic ulcer, hypertension
History of Present Illness (HPI) Describe the course of the patient's illness, including when it began, character of the symptoms, location where the symptoms began aggravating or alleviating factors pertinent positives and negatives. Describe past illnesses or surgeries, and past diagnostic testing. Past Medical History (PMH) Past diseases, surgeries, hospitalizations medical problems history of diabetes, hypertension, peptic ulcer disease, asthma, myocardial infarction, cancer. In children include birth history, prenatal history, immunizations, and type of feedings.
After the lesson of Helicobacter pylori and peptic ulcer disease, an infectious contribution to the pathogenesis of IBD is plausible. Despite intensive pursuit of a specific infectious cause for IBD, this subject remains controversial. However, an aetiological role for a single pathogenic micro-organism in the pathogenesis of IBD has not been established (Shanahan, 2004). On the other hand, compelling data from murine models of colitis as well as circumstantial evidence in patient-related studies, implicate the enteric microbiota in the pathogenesis of both Crohn's disease and ulcerative colitis (Table 5.1). The level at which the dysregulated immunity to commensal organisms occurs has not been identified. It remains unclear whether the associated inflammatory responses, both within the gut and at extra-intestinal sites, are elicited in response to a specific subset of intestinal microbes. Alternatively, sensing of commensal bacteria in general may be affected. Nevertheless, what is...
Pain is classically described as acute, severe, unrelenting and diffuse reported in the chest, neck and abdomen and with radiation to the back and shoulders. Back pain may be the predominant symptom. Pain is often exacerbated by swallowing. Dysphagia, dyspnea, hematemesis, and cyanosis can be present as well. Less acute and atypical presentations are also described. Esophageal perforation is often ascribed to acute myocardial infarction (MI), pulmonary embolus, peptic ulcer disease, aortic catastrophe, or acute abdomen, resulting in critical delays in diagnosis, the most important factor in determining morbidity and mortality outcome.
Infection with the Gram-negative microaerophilic bacterium Helicobacter pylori is typically acquired in childhood. About 10 of patients develop symptoms of gastritis, peptic ulcer disease or MALT lymphoma, but anaemia and growth retardation is also associated with H. pylori colonisation in children (Czinn, 2005). The infection is a relevant health problem since approximately half of the world population is infected with H. pylori. In particular, high prevalence rates exist in developing countries and in populations with low socio-economic standard and poor hygienic conditions. H. pylori can be eradicated by anti-microbial therapy (typically amoxicillin plus clarithromycin
Cholecystitis, peptic ulcer disease, or hepatitis can cause nausea and vomiting and should be excluded. Gastroenteritis, appendicitis, pyelonephritis, and pancreatitis also should be excluded. Obstetric explanations for nausea and vomiting may include multiple pregnancies or a hydatidiform mole.
Ironically, while prostaglandins are typically described as mediators of inflammation, these substances exert a wide range of anti-inflammatory effects (Figure 3). For example, prostaglandins are potent inhibitors of the release of tumor necrosis factor a (TNFa) and IL-1 from macrophages, and potent inhibitors of TNFa and platelet-activating factor from mast cells. Prostaglandins also suppress the release of a number of proinflammatory mediators from platelets. On the other hand, NSAIDs, by suppressing endogenous prostaglandin synthesis, can increase the release of a number of proinflammatory mediators from various cells, and can therefore enhance an inflammatory reaction (while simultaneously reducing edema and pain). Prostaglandins have also been shown to be potent inhibitors of adhesion molecule expression on the vascular endothelium (e.g. ICAM-i) and on leukocytes (e.g. CD11 CD18), thereby reducing the ability of leukocytes to extravasate. Conversely, NSAIDs have been shown to...
The presence of abdominal pain in nausea and vomiting of pregnancy or hyperemesis gravidarum is highly unusual and should suggest another diagnosis. Occasionally, women with ruptured ectopic pregnancies present with nausea and vomiting as well as diarrhea and abdominal pain. After the first trimester, the volume of the gallbladder increases during fasting and postcontraction after a meal. Also, biliary sludge seems to increase in pregnancy in 30 percent, predisposing to stone formation.7 Cholelithiasis and cholecystitis are more common in pregnant women than in women of comparable age and health status who are not pregnant. Differential diagnosis of vomiting or vomiting with abdominal pain should include cholecystitis, cholelithiasis, gastroenteritis, pancreatitis, hepatitis, peptic ulcer, pyelonephritis, ectopic pregnancy, and fatty liver of pregnancy.
Khuroo MS, Yattoo GN, Javid G, et al A comparison of omeprazole and placebo for bleeding peptic ulcer. N Engl J Med 336 1054, 1997. 19. Schaffalitzky de Muckadell OB, Havelund T, Harding H, et al Effect of omeprazole on the outcome of endoscopically treated bleeding peptic ulcers Randomized double-blind placebo-controlled multicentre study. Scand J Gastroenterol 32 320, 1997. 22. Santander C, Gravalos RG, Gomez-Cedenilla A, et al Antimicrobial therapy for Helicobacter pylori infection versus long-term maintenance antisecretion treatment in the prevention of recurrent hemorrhage from peptic ulcer Prospective nonrandomized trial on 125 patients. Am J Gastroenterol 91 1549, 1996.
Glucocorticoids act primarily by inhibiting T-cell and macrophage function. In addition to immune suppression, long-term use of glucocorticoids suppresses endogenous adrenal function, which may produce Cushing syndrome and cause hypertension, glucose intolerance, osteoporosis, avascular necrosis of the hip, cataracts, pancreatitis, peptic ulcer disease, delayed wound healing, behavioral disorders, and malignancies.
Alcohols, including glycols, are much stronger CNS depressants than aliphatics are and slightly more irritating. As carbon chain length increases, irritation decreases but lipophi-licity increases, as does systemic toxicity. Methanol is less inebriating than ethanol but has the unusual property of destroying the optic nerve. Fifteen milliliters can cause blindness. As with ethanol, it is metabolized by a zero-order rate mechanism, but at one-seventh the rate. Ethanol acts as an irritant by dehydrating protoplasm. An initial stimulant effect is caused by depression of control mechanisms in the brain. Pain sensitivity is greatly reduced. Cutaneous (skin) blood vessels become dilated. The resulting increased heat loss can be dangerous in cold weather. It increases gastric secretion, which can aggravate stomach ulcers. It causes fat accumulation and cirrhosis in the liver. The latter can be fatal itself or can cause progression to cancer. Ethanol increases urine flow through a mechanism...
Occasionally, drugs may have serious adverse effects such as allergic reactions, hepatitis, cardiac arrhythmias and gastric ulcer. Despite this, attributing an adverse event to a specific treatment can sometimes be difficult, particularly when the event is rare, unexpected, or appears a long time after the start of treatment. It can also be difficult to recognize an adverse effect when it may occur as part of the natural history of the underlying condition. These challenges are discussed in Chapter 4.
The lines of disease causation have become blurred at the genetic level by the discovery of microbe-induced disease processes not originally associated with microbial causes and only recently identified by genotypic approaches. The latter include viral-induced cancerso (83-85), schizophrenia (86), and diabetes mellitus (87). Borrelia burgdorferi DNA incorporated in the genome of arthritic mice (88) and detected in humans (89) and a list of organisms referenced by Relman (87) have been found using genotypic approaches to detect microbial genes inserted into the genome of man and animals and therefore associated with specific diseases. These include Helicobacter pylori (peptic ulcer disease), hepatitis C virus (non-A, non-B hepatitis), bartonella henselae (Bacillary angiomatosis), Tropheryma whippelii (Whipple's disease), sin nombre virus (Hantavirus pulmonary syndrome), and Kaposi's sarcoma-associated herpes virus (Kaposi sarcoma). In this context Fredricks and Relman have called for...
Lactic acid bacteria are often able to survive acidic gastric conditions and it has therefore been proposed that they may have a beneficial influence during the eradication of H. pylori. It has been reported that both the inhibitory substances produced and the specific strains may influence the survival of Helicobacter, and studies have been conducted, particularly with a L. johnso-nii strain. It has been shown that there is good in vitro inhibition and that fermented milk containing the strain has a positive effect when consumed during Helicobacter eradication therapy. However, more controlled human studies in different populations need be conducted to verify this effect.
A mnemonic sometimes used for the signs and symptoms of hypercalcemia is stones (renal calculi), bones (osteolysis), moans (psychiatric disorders), and groans (peptic ulcer disease and pancreatitis). The most common gastrointestinal symptoms are anorexia and constipation, but these are very nonspecific.
NSAID have several advantages over opioid analgesics. Their use is not associated with respiratory depression or gastric stasis and, as they are not controlled drugs, they are readily available. However, their use is associated with potentially serious side effects that include gastro-intestinal haemorrhage, gastric ulceration, renal impairment and an increased risk of post operative bleeding due to impairment of platelet function. NSAID are contra-indicated in patients with a history of peptic ulcer disease, gastro-intestinal bleeding, renal impairment, previous hypersensitivity reactions to aspirin or NSAID, asthma and bleeding diathesis. They should be avoided in the dehydrated or hypovolaemic patient and care should be taken when using NSAID in the elderly.
BLEEDING There are several systemic processes that can result in GI bleeding. Upper GI bleeding is usually the result of peptic ulcer disease, varices, or gastritis. Lower GI bleeding can be due to not only the previously mentioned diseases, but also due to infectious colitis, coagulopathies, ulcerative colitis, and Crohn's disease. Two other illnesses can cause abdominal pain and bleeding Henoch-Schonlein purpura (HSP) and hemolytic-uremic syndrome (HUS) On the other hand, if the child is sick- or ill-appearing or shocklike or has petechiae, one must consider vascular malformation, Meckel's diverticulum, intestinal duplication, or sepsis. In adolescents, one must consider stress ulceration, peptic ulcer disease, and inflammatory bowel disease. Sepsis, severe gastroenteritis, HSP, and HUS should also be part of the differential diagnoses.
The classic symptom of ulcer is dyspepsia, a burning epigastric pain usually occurring 2-3 h after meals and at night (between 11.00 p.m. and 2.00 a.m.) when acid secretion is maximal. Relief often occurs with ingestion of food and alkali. Although suggestive of peptic ulcer, dyspepsia is not a sensitive or specific measure of peptic ulcer. Only about 50 of DU patients have the typical symptom of dyspepsia. Some ulcer patients develop a stomach that is easily irritated by food, mechanical distention, or other chemical stimuli. The sensitivity of radiography for the diagnosis of ulcers ranges from 50 to 90 , depending on the technical skill of the radiographer and the size and location of the ulcer. Fiberoptic endoscopy is a sensitive, specific, and safe method for diagnosing peptic ulcers. It gives the advantage of direct visualization and access to tissue for biopsy. Data from placebo-controlled trials show that untreated peptic ulcers can heal within 4 weeks in 30 of GU and 40 of DU...
Primary hyperparathyroidism may present in a variety of ways. Patients may be asymptomatic and the disease may be recognized through routine screening laboratory tests. Other patients may present with severe renal or bone disease. Because calcium affects nearly every organ system, calcium dysregulation may present clinically with a multitude of signs and symptoms. The most common symptoms include fatigue, weakness, depression, arthralgia and constipation. Conditions associated with hyperparathyroidism include kidney stones, chondrocalcinosis, osteitis fibrosa cystica, osteoporosis, hypertension, gout, peptic ulcer disease and pancreatitis. Patients with excess PTH production may experience progressive loss of bone mineralization. This is manifested as subperiosteal resorption, osteoporosis and pathologic fractures. Skeletal involvement is most readily demonstrated by radiographic films.
The side effects of aspirin are mainly gastrointestinal and dose related. They can be reduced by using diluted or buffered aspirin solutions, lowest possible doses, or concurrent antacid or H2 antagonist administration. In the setting of acute ischemia, the delay in absorption of enteric-coated aspirin may be best avoided. Due to the substantial benefits of aspirin therapy during AMI, it should not be withheld from patients with minor contraindications (vague allergy, history of remote peptic ulcer, or gastrointestinal bleeding).4 Other antiplatelet agents, such as ticlopidine, can be substituted if true aspirin allergy or active peptic ulcer disease exists. 4 The aspirin dose should be at least 160 mg.
Octreotide has been shown to be as effective as sclerotherapy in acute variceal bleeding. 14 Both agents, when used in addition to sclerotherapy, are more effective than sclerotherapy alone.1 l6 These agents possess the advantages of vasopressin, with considerably fewer side effects. They should be considered useful adjuncts, either before endoscopy or when endoscopy is unsuccessful, contraindicated, or unavailable. 17 treatment of bleeding peptic ulcers.18 9 therapy has been shown to be beneficial in patients with varices, in preventing both initial variceal bleeds and rebleeding. i2 Additionally, the treatment of Helicobacter pylori infection with antibiotics reduces the recurrence of peptic ulcer and rebleeding. 22 However, the use of H2 antagonists in acute upper GI hemorrhage remains of unproven benefit,23 with no conclusive evidence for reduction in the rates of rebleeding, surgery, or death.
In the United States, about 150,000 patients per year are admitted to the hospital with gastrointestinal bleeding due to peptic ulcer disease. 19 Factors predicting death Hospitalization in an intensive care setting is indicated for all patients with significant upper gastrointestinal bleeding due to peptic ulcers. If clinical and endoscopic features suggest a low risk of rebleeding, a ward bed may be acceptable.
Perforation is heralded by the abrupt onset of severe epigastric pain as gastric or duodural contents spill into the peritoneal cavity, followed by the development of chemical and then bacterial peritonitis. Patients may not have a prior history of peptic ulcer disease and may in fact have no antecedent history of ulcer-like symptoms. Elderly patients may not have dramatic pain or impressive peritoneal findings.
Obstruction occurs because of scarring of the gastric outlet due to chronic peptic ulcer disease, edema due to an active ulcer, or some combination of both. Resulting symptoms include abdominal fullness, nausea, and vomiting, and signs may include abdominal distention and a succussion splash. Dehydration and electrolyte imbalances may occur. Treatment includes rehydration with intravenous fluids, correction of electrolyte abnormalities, and relief of distention with nasogastric suction. Hospitalization is almost always indicated. The outlet may open as edema subsides, but surgical correction is often necessary.
Carbonic anhydrase is present in high concentrations in the gastric epithelium, where it plays a major role in gastric acid secretion. Inhibition of this enzyme has been shown to inhibit basal and stimulated gastric acid secretion in both experimental animals and in humans. In fact, acetazolamide has been used in the treatment of patients with peptic ulcer with a reported response rate of greater than 90 . In parietal cells, protons derived from water molecules are secreted into the gastric lumen via the H-K ATPase, while the corresponding hydroxyl ions, via carbonic anhydrase, are converted to HC03. The bicarbonate ions exit the basolateral surface of the cell in exchange for chloride. Chloride is secreted into the lumen by way of a KCL symporter. Potassium ions secreted on the symporter are largely recycled across the apical membrane in exchange for protons via the apical H-K ATPase. Carbonic anhydrase is also found in non-acid-secreting cells of the stomach. These cells secrete...
The only time surgery should serve as the first-line therapy is in patients with giant (greater than 3 cm) gastric ulcers.4,5 Elective surgery is the first-line therapy in these patients because of the high rate of complications associated with these lesions and the high rate of medical failure. Otherwise, surgical therapy is reserved for complications resulting from ulcers or for the management of ulcers refractory to medical therapy. Ulcers are considered refractory to medical therapy if the ulcer fails to heal with optimal medical management, or if the patient is noncompliant or does not tolerate medical treatment. By and large, surgery is reserved for dealing with complications that result from gastric ulcers such as bleeding, perforation, and obstruction. Elective surgery for refractory gastric ulcers is rarely performed. Type I gastric ulcers are treated with distal gastrectomy, including the ulcer, and a gastroduodenal anastomosis, or Billroth I (Fig. 9-3). Type II ulcers can...
Stress gastritis develops in critically ill patients.4,5 They are characterized by their diffuse and superficial nature and occurrence in the presence of trauma, burns, shock, and sepsis specifically, in the setting of prolonged ventilation and coagulopathy. They manifest with bleeding which in the extreme can compromise the hemodynamic status of an already critically ill patient. There are three types of stress ulcers that are associated with specific settings. Stress ulcers or erosive gastritis is the prototypical diffuse lesions seen in the stomach of critically ill patients. Curling ulcers are diffuse ulcers which can be seen in the stomach, duodenum, and occasionally throughout the GI tract and are associated with burns. Cushing ulcers are usually confined to the stomach and duodenum and are seen in the setting of head injury. Because of the association with critical illness, all patients who remain on a ventilator for over 48 h and or have an underlying coagulopathy should...
The anterior pararenal compartment is the most common site of extraperitoneal infection. Of 160 patients with extraperitoneal abscess reviewed by Altemeier and Alexander,3 the process was confined to the anterior pararenal space in 84 (52.5 ). Most arise from primary lesions of the alimentary tract, especially the colon, ex-traperitoneal appendix, pancreas, and duodenum. The exudates originate from perforating malignancies, inflammatory conditions, penetrating peptic ulcers, and accidental or iatrogenic trauma.3,67 Hemorrhage from a
Patients with Zollinger-Ellison syndrome present with recalcitrant peptic ulcer disease, unusual ulcer sites along the gastrointestinal tract, and diarrhea. Symptom temporization has been achieved with proton pump inhibitors and histamine2-receptor antagonists. Even in the setting of controlled symptoms, the significant potential for malignancy warrants operative management. Tumors may be identified by a combination of endoscopic ultrasound, CT scanning, and visceral angiography. Enucleation, excision, and pancreatic resection are surgical options. Tumors in the head of the pancreas may require the Whipple procedure. Five-year survival rate exceeds 80 percent for resectable lesions and decrease to 20 percent for patients with metastatic disease.
Lower incidences of urinary tract infection and now has been shown to have a capacity to decrease peptic ulcer caused by Helicobacter pylori. Isolated compounds from cranberry have been shown to reduce the risk of CVD and cancer. Functional phenolic antioxidants from cranberry such as ellagic acid have been well documented to have antimutagenic and anticarcinogenic functionality. Even though many benefits have been associated with phytochemicals from cranberry, such as ellagic acid, their mechanism of action is still not very well understood. Emerging research exploring the mechanism of action of these phyto-chemicals from cranberry usually follows a reductionist approach, and is often focused on the disease or pathological target. These approaches to understanding the mechanism of action of phytochemicals have limitations as they are unable to explain the overall preventive mode of action of phenolic phytochemicals. The current proposed mechanisms of action of these phenolic...
Some of the grain can be replaced by oils and fat, which contain more than twice the energy per unit of weight but do not disturb the environment of the hindgut as drastically as does starch. The diet should contain adequate fiber in order to maintain an effective environment in the hindgut, to prevent equine gastric ulcers, and to decrease the incidence of vices such as wood chewing. The ratio of roughage to concentrates should be
Achieve the safe and effective use of the drug. Pharmacogenetics and pharmacogenomics are the sciences of understanding the correlation between an individual patient's genetic makeup (genotype) and their response to drug treatment. They already have influenced therapeutics. For a drug that is primarily metabolized by CYP2D6, approximately 7 of Caucasians will not be able to metabolize the drug, but the percentage for other racial populations is generally far lower. Similar information is known for other pathways, prominently, CYP2C19 and -acetyl transferase. For example, codeine is metabolized to its active molecule, and about 10 of the population are rapid metabolizers and only need a much smaller dose for the same pharmacodynamic outcome. Omeprazole, used to treat peptic ulcers, is poorly metabolized related to SNPs in the CYP2C19 liver enzyme in 2.5-6 of Caucasians and 15-23 of Asians. For thiopurine, an antimetabolite used in cancer chemotherapy, the dose is 1 10 for the poor...
NSAID-induced ulcers are more commonly gastric ulcers. The prevalence of ulcers is more than 15 among chronic NSAID users and less than 4 among those using NSAIDs for less than 1 year. Gastritis or H. pylori infection is not a prerequisite for NSAID-induced ulcers. The damaging effect of NSAIDs is thought to be due to their effect on pros-taglandin synthesis. Endogenous prostaglandin aid in maintaining gastric mucosal blood flow and epithelial integrity and promote epithelial regeneration. NSAIDs reduce prostaglandin synthesis thus reducing the effect of prostaglandin in mucosal defense.
Since its description in 1983, H. pylori has been implicated as a causative agent of gastritis, gastric adenocarcinomas, gastric B cell lymphoma, and peptic ulcer disease. In developed countries, the prevalence increases with age, whereas in developing countries, most children are infected by the age of 10 years. Transmission is believed to be by person-to-person spread, although the means of spread is unclear. Intrafamilial transmission is suggested by several epidemiologic studies. Acute infection with H. pylori induces a neutro-philic gastritis accompanied by transient hypo-chlorhydria. Chronic infection results in a chronic superficial gastritis characterized by neutrophils, eosinophils, and B and T lymphocytes. Inflammation is a result of bacterial products (e.g., VacA, CagA) and factors produced by gastric epithelial cells (e.g., cytokines). Most individuals with chronic infection remain asymptomatic. One in six chronically infected individuals will develop peptic ulcer disease....
Classic signs of acute abdomen are often missing in patients with spinal cord injury. The diagnosis of perforated peptic ulcer, intestinal obstruction, appendicitis, peritonitis, cholecystitis, and renal abscess is often delayed because the classic findings of abdominal muscle rigidity, rebound, abdominal tenderness, fever, and leukocytosis may not be present.12 In patients with spinal cord injury, other signs and symptoms suggestive of an acute abdomen are autonomic dysreflexia, referred shoulder tip pain, abdominal pain, abdominal distention, change in muscle spasticity, nausea and vomiting, and a sense of apprehension. 1 1 and 14 A high index of suspicion, along with laboratory and imaging tests, is necessary to avoid missing the diagnosis. One confounding factor is that urinary tract infections may present with similar signs and symptoms. Thus, the finding of pyuria or bacteruria alone should not be used to exclude the diagnosis of an acute abdomen. 13 Unexplained leukocytosis is...
Injuries may be self-inflicted, accidental, or sustained by assault from others. Developmentally disabled individuals are quite vulnerable to assault, and it is important that health care providers be aware of the risk of abuse and their duty to report suspicious injuries. However, the majority of injuries that mentally retarded individuals experience are the result of self-injurious behaviors. Although self-injurious behaviors may be self-stimulating or compulsive, it is essential to rule out medical and environmental precipitants. This is particularly true if the self-injurious behaviors are of sudden onset. Bosch and colleagues found that in 28 percent of their patients, treatment of previously undiagnosed, painful medical conditions resulted in significant reductions in self-injurious behaviors. 16 Constipation, gastrointestinal reflux, and peptic ulcer disease were the most common disorders. In these cases, there had often been a cyclic pattern to the self-injurious behaviors or...
Midepigastric pain is associated with early stages of acute appendicitis, acute small bowel obstruction, peptic ulcer disease, and acute pancreatitis. Pancreatitis, depending on the etiology of the inflammation, including gallstones, alcohol or idiopathic causes, requires different types of intervention. Gallstone pancreatitis is one of the few types of pancreatitis that require early surgical intervention.
Central amygdaloid nucleus projects to a wide variety of autonomic-related cell groups, including the lateral hypothalamus, the periaqueductal gray, the parabrachial nucleus, the nucleus of the solitary tract, the dorsal vagal nucleus, and the ventrolateral medulla. Through these projections, the amygdala can influence heart rate and blood pressure, gut and bowel function, respiratory function, bladder function, etc. For example, stimulation of the central nucleus can cause stomach ulcers as well as changes in cardiovascular function.
Metabolic alkalosis may be caused either by the excessive loss of acid or intake of alkali. The latter may be iatrogenic or factitious, with the excessive intake of prescribed antacids (such as sodium bicarbonate for heartburn or peptic ulcer disease) - the 'milk-alkali' syndrome. The loss of acid-rich gastric secretions in severe vomiting, for example, in cases of gastric outlet obstruction (due to pyloric stenosis, or a consequence of peptic ulcer disease), also leads to alkalosis. Compensation is by reducing ventilation to promote retention of CO2 and thus balance the Henderson-Hasselbalch equation. Treatment is of the underlying condition rather than by administration of acid.
Ideally) invokes an explanatory etiology, a prognostic picture, and a set of treatment options, all drawing upon the theories and knowledge base of medical science. Since the eighteenth century, disease classifications have progressively moved from a basis in the patient's reported symptoms to one grounded on the pathological lesions and processes exposed after death or, by medical technologies, in the living (Engelhardt, 1986 Foucault). Hence, dyspepsia has become peptic ulcer disease. This shift has greatly advanced the explanatory and therapeutic powers of modern medicine, but it has also diminished the attention paid to the patient's experience.
Approximately 80 of patients have an initial response to high-dose glucocorticoids. Nevertheless, only 20-30 have a sustained response following discontinuation of therapy. Several patients maintain control of their hemolytic process on low- or medium-dose glucocorticoid therapy. For the patients who are steroid dependent, the initial and long-term side-effects of steroids must be considered. These include gastritis, peptic ulcer disease, emotional lability, exacerbation of diabetes and hypertension, electrolyte imbalance, increased appetite and weight gain, moon-like faces, osteoporosis, myopathy and increased susceptibility to infection. The severity of these side-effects relates to both dosage and duration of therapy. Splenectomy is usually recommended for patients who are unresponsive to steroids or who require more than 10-20 mg per day or 20-25 mg every other day for maintenance. Each patient requires individual evaluation of underlying disease, surgical risk, extent of anemia...
Patients with gastroesophageal reflux disease, gastric ulcer, and duodenal ulcer. Gastrointestinal motility is influenced by sex hormones (51,52), implying that gender-based disparity in motility may exist and that the transit time in women may vary throughout pregnancy and the menstrual cycle. Estrogen and its equivalents may inhibit gastric emptying (53,54), whereas the effects of progesterone depends on its concentration (55,56). Gastric transit time has been demonstrated by many researchers to be slower in females than males (57-61).
The attribution of these patients' illness to hypo-glycemia had its origins in the early 1950s with the appearance, in the US, of a book by Drs Abrahams and Pezet entitled 'Body, Mind and Sugar.' Other American practitioners, notably John Tintera, founder of the Hypoglycemia Foundation Inc., Stephen Gyland, Harry Saltzer and, others, including the medical writer Carlton Fredericks, publicized the concept. This led to 'hypoglycemia' being held, by a large section of the public, responsible for such diverse diseases as coronary artery disease, allergy, asthma, rheumatic fever, susceptibility to viral infections, epilepsy, gastric ulcer, alcoholism, suicide, and even homicide, as well as for a whole galaxy of symptoms in their own right. 'Hypoglycemia' was treated as though it were a disease entity and asserted by its advocates to be 'one of the most common illnesses in the United States' and that because of it 'thousands of Americans have forgotten, or perhaps never known, what it is...