Peptic ulcer pathophysiology: Difference between revisions

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*[[Non-steroidal anti-inflammatory drug|Nonsteroidal anti-inflammatory drugs]] (NSAIDs)
*[[Non-steroidal anti-inflammatory drug|Nonsteroidal anti-inflammatory drugs]] (NSAIDs)
===Role of Helicobacter pylori===
===Role of Helicobacter pylori===
*[[Helicobacter pylori]] is gram-negative, spiral-shaped, motile , urease positive  [[bacteria]].
*[[Helicobacter pylori]] is gram-negative, spiral-shaped, motile , urease positive  [[bacteria]]
*Factors help in penetration and growth of [[Helicobacter pylori]] are :<ref name="pmid16847081">{{cite journal |vauthors=Kusters JG, van Vliet AH, Kuipers EJ |title=Pathogenesis of Helicobacter pylori infection |journal=Clin. Microbiol. Rev. |volume=19 |issue=3 |pages=449–90 |year=2006 |pmid=16847081 |pmc=1539101 |doi=10.1128/CMR.00054-05 |url=}}</ref><ref name="pmid118091812">{{cite journal |vauthors=Huang JQ, Sridhar S, Hunt RH |title=Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: a meta-analysis |journal=Lancet |volume=359 |issue=9300 |pages=14–22 |year=2002 |pmid=11809181 |doi=10.1016/S0140-6736(02)07273-2 |url=}}</ref>
*Factors help in penetration and growth of [[Helicobacter pylori]] are :<ref name="pmid16847081">{{cite journal |vauthors=Kusters JG, van Vliet AH, Kuipers EJ |title=Pathogenesis of Helicobacter pylori infection |journal=Clin. Microbiol. Rev. |volume=19 |issue=3 |pages=449–90 |year=2006 |pmid=16847081 |pmc=1539101 |doi=10.1128/CMR.00054-05 |url=}}</ref><ref name="pmid118091812">{{cite journal |vauthors=Huang JQ, Sridhar S, Hunt RH |title=Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: a meta-analysis |journal=Lancet |volume=359 |issue=9300 |pages=14–22 |year=2002 |pmid=11809181 |doi=10.1016/S0140-6736(02)07273-2 |url=}}</ref>
** [[Bicarbonate]]-mediated chemotactic motility of  [[Helicobacter pylori]]  facilitates its penetration  
** [[Bicarbonate]]-mediated chemotactic motility of  [[Helicobacter pylori]]  facilitates its penetration  
** Neutral pH favors the growth of [[helicobacter pylori]].
** Neutral pH favors the growth of [[helicobacter pylori]]


====Immunological response====
====Immunological response====
Factors responsible for immunological response of  [[Helicobacter pylori]]  are :
Factors responsible for immunological response of  [[Helicobacter pylori]]  are :
* [[Helicobacter pylori]]  [[infection]] triggers local production various [[proinflammatory]] mediators ([[cytokines]], [[neutrophil]] infiltration, specific T- and B- cells).
* [[Helicobacter pylori]]  [[infection]] triggers local production various [[proinflammatory]] mediators ([[cytokines]], [[neutrophil]] infiltration, specific T- and B- cells)


*Of all the [[cytotoxins]] and [[virulence factors]] Cag A, VacA, and OipA play a key role in the pathogenesis of  [[Helicobacter pylori]]  infection.
*Of all the [[cytotoxins]] and [[virulence factors]] Cag A, VacA, and OipA play a key role in the pathogenesis of  [[Helicobacter pylori]]  infection
*Cag A, VacA, and OipA not only  helps in the colonization of  [[Helicobacter pylori]]  but and also modulates host's immune system.
*Cag A, VacA, and OipA not only  helps in the colonization of  [[Helicobacter pylori]]  but and also modulates host's immune system
*[[Bacterial]] factors and [[complement]] activation leads to neutrophilic activation including reactive [[oxygen]],release of [[leukocytes]] [[enzymes]] and [[leukotriens]] lead to mucosal injury <ref>url=http://www.nejm.org/doi/full/10.1056/NEJM199003293221307<nowiki> |title=Pathogenesis of Peptic Ulcer and Implications for Therapy — NEJM |format= |work= |accessdate=}}</nowiki></ref> <ref name="pmid8730255">{{cite journal |vauthors=Logan RP |title=Adherence of Helicobacter pylori |journal=Aliment. Pharmacol. Ther. |volume=10 Suppl 1 |issue= |pages=3–15 |year=1996 |pmid=8730255 |doi= |url=}}</ref><ref name="pmid8730257">{{cite journal |vauthors=Crabtree JE |title=Gastric mucosal inflammatory responses to Helicobacter pylori |journal=Aliment. Pharmacol. Ther. |volume=10 Suppl 1 |issue= |pages=29–37 |year=1996 |pmid=8730257 |doi= |url=}}</ref><ref name="pmid7863238">{{cite journal |vauthors=Ernst PB, Jin Y, Reyes VE, Crowe SE |title=The role of the local immune response in the pathogenesis of peptic ulcer formation |journal=Scand. J. Gastroenterol. Suppl. |volume=205 |issue= |pages=22–8 |year=1994 |pmid=7863238 |doi= |url=}}</ref><ref name="urlPathogenesis of Peptic Ulcer and Implications for Therapy — NEJM"><nowiki>{{cite web </nowiki><nowiki><ref name="pmid16847081"></nowiki>{{cite journal |vauthors=Kusters JG, van Vliet AH, Kuipers EJ |title=Pathogenesis of Helicobacter pylori infection |journal=Clin. Microbiol. Rev. |volume=19 |issue=3 |pages=449–90 |year=2006 |pmid=16847081 |pmc=1539101 |doi=10.1128/CMR.00054-05 |url=}}</ref>
*[[Bacterial]] factors and [[complement]] activation leads to neutrophilic activation including reactive [[oxygen]],release of [[leukocytes]] [[enzymes]] and [[leukotriens]] lead to mucosal injury <ref>url=http://www.nejm.org/doi/full/10.1056/NEJM199003293221307<nowiki> |title=Pathogenesis of Peptic Ulcer and Implications for Therapy — NEJM |format= |work= |accessdate=}}</nowiki></ref> <ref name="pmid8730255">{{cite journal |vauthors=Logan RP |title=Adherence of Helicobacter pylori |journal=Aliment. Pharmacol. Ther. |volume=10 Suppl 1 |issue= |pages=3–15 |year=1996 |pmid=8730255 |doi= |url=}}</ref><ref name="pmid8730257">{{cite journal |vauthors=Crabtree JE |title=Gastric mucosal inflammatory responses to Helicobacter pylori |journal=Aliment. Pharmacol. Ther. |volume=10 Suppl 1 |issue= |pages=29–37 |year=1996 |pmid=8730257 |doi= |url=}}</ref><ref name="pmid7863238">{{cite journal |vauthors=Ernst PB, Jin Y, Reyes VE, Crowe SE |title=The role of the local immune response in the pathogenesis of peptic ulcer formation |journal=Scand. J. Gastroenterol. Suppl. |volume=205 |issue= |pages=22–8 |year=1994 |pmid=7863238 |doi= |url=}}</ref><ref name="urlPathogenesis of Peptic Ulcer and Implications for Therapy — NEJM"><nowiki>{{cite web </nowiki><nowiki><ref name="pmid16847081"></nowiki>{{cite journal |vauthors=Kusters JG, van Vliet AH, Kuipers EJ |title=Pathogenesis of Helicobacter pylori infection |journal=Clin. Microbiol. Rev. |volume=19 |issue=3 |pages=449–90 |year=2006 |pmid=16847081 |pmc=1539101 |doi=10.1128/CMR.00054-05 |url=}}</ref>
*[[Helicobacter pylori]]  secretes various enzyme :[[Urease]],[[Phospholipase|Phospholipases]],[[Alcohol dehydrogenase]] and Catalases- causes damage the host [[gastric]] muscosa by generating [[toxic]] metabolities<ref name="pmid8730260">{{cite journal |vauthors=Mobley HL |title=The role of Helicobacter pylori urease in the pathogenesis of gastritis and peptic ulceration |journal=Aliment. Pharmacol. Ther. |volume=10 Suppl 1 |issue= |pages=57–64 |year=1996 |pmid=8730260 |doi= |url=}}</ref><ref name="pmid8730261">{{cite journal |vauthors=Nilius M, Malfertheiner P |title=Helicobacter pylori enzymes |journal=Aliment. Pharmacol. Ther. |volume=10 Suppl 1 |issue= |pages=65–71 |year=1996 |pmid=8730261 |doi= |url=}}</ref><ref name="pmid2801678">{{cite journal |vauthors=Slomiany BL, Kasinathan C, Slomiany A |title=Lipolytic activity of Campylobacter pylori: effect of colloidal bismuth subcitrate (De-Nol) |journal=Am. J. Gastroenterol. |volume=84 |issue=10 |pages=1273–7 |year=1989 |pmid=2801678 |doi= |url=}}</ref>
*[[Helicobacter pylori]]  secretes various enzyme :[[Urease]],[[Phospholipase|Phospholipases]],[[Alcohol dehydrogenase]] and Catalases- causes damage the host [[gastric]] muscosa by generating [[toxic]] metabolities<ref name="pmid8730260">{{cite journal |vauthors=Mobley HL |title=The role of Helicobacter pylori urease in the pathogenesis of gastritis and peptic ulceration |journal=Aliment. Pharmacol. Ther. |volume=10 Suppl 1 |issue= |pages=57–64 |year=1996 |pmid=8730260 |doi= |url=}}</ref><ref name="pmid8730261">{{cite journal |vauthors=Nilius M, Malfertheiner P |title=Helicobacter pylori enzymes |journal=Aliment. Pharmacol. Ther. |volume=10 Suppl 1 |issue= |pages=65–71 |year=1996 |pmid=8730261 |doi= |url=}}</ref><ref name="pmid2801678">{{cite journal |vauthors=Slomiany BL, Kasinathan C, Slomiany A |title=Lipolytic activity of Campylobacter pylori: effect of colloidal bismuth subcitrate (De-Nol) |journal=Am. J. Gastroenterol. |volume=84 |issue=10 |pages=1273–7 |year=1989 |pmid=2801678 |doi= |url=}}</ref>
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'''Role of Helicobacter pylori in causing gastric ulcer'''
'''Role of Helicobacter pylori in causing gastric ulcer'''
* Colonzation:
* Colonzation:
**The colonization of virulent CagA-positive [[Helicobacter pylori]] strains leads to the degeneration of surface epithelial cells.
**The colonization of virulent CagA-positive [[Helicobacter pylori]] strains leads to the degeneration of surface epithelial cells
**This degeneration results in increased exfoliation of surface epithelial cells.
**This degeneration results in increased exfoliation of surface epithelial cells  
**The exfoliation mediated compensatory cell proliferation leads to the movement of immature cells to the foveolae and surface.
**The exfoliation mediated compensatory cell proliferation leads to the movement of immature cells to the foveolae and surface
*Immature cells leads to impaired mucin and bicarbonate production  and the integrity of the mucous barrier may be compromised.
*Immature cells leads to impaired mucin and bicarbonate production  and the integrity of the mucous barrier may be compromised  
*All of above factors lead to activation of complement via the alternative pathway and the release of chemical mediators by mast cells and activated polymorphs may lead to microvascular disturbances and focal [[ischemic]] damage to the surface epithelium
*All of above factors lead to activation of complement via the alternative pathway and the release of chemical mediators by mast cells and activated polymorphs may lead to microvascular disturbances and focal [[ischemic]] damage to the surface epithelium
*[[Helicobacter pylori]]  infection down-regulates E-cadherin expression in [[gastric]] epithelial cells which affect the resistance of the mucosa to acid attack
*[[Helicobacter pylori]]  infection down-regulates E-cadherin expression in [[gastric]] epithelial cells which affect the resistance of the mucosa to acid attack
Line 103: Line 103:


==Gross Pathology==
==Gross Pathology==
*[[Gastric|Gastric ulcers]] are most often localized on the lesser curvature of the [[stomach]].
*[[Gastric|Gastric ulcers]] are most often localized on the lesser curvature of the [[stomach]]  
*[[Duodenal]] [[ulcers]] are more located at bulb of duodenum.
*[[Duodenal]] [[ulcers]] are more located at bulb of duodenum  
*Characteristic findings of a [[peptic ulcer]] on gross pathology include:
*Characteristic findings of a [[peptic ulcer]] on gross pathology include:
**Round to oval
**Round to oval
**2 to 4 cm diameter
**2 to 4 cm diameter
**Smooth base with perpendicular borders.
**Smooth base with perpendicular borders.
**Parietal scarring with radial folds may be evident in the surrounding mucosa.
**Parietal scarring with radial folds may be evident in the surrounding mucosa
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**Fibrinoid necrosis
**Fibrinoid necrosis
**Granulation tissue  
**Granulation tissue  
**Fibrous tissue. The fibrous base of the ulcer may contain vessels with thickened wall or with thrombosis.<ref name="pathologyatlas">{{cite web | url=http://www.pathologyatlas.ro/Peptic%20ulcer.html| title=ATLAS OF PATHOLOGY|accessdate=2007-08-26}}</ref>
**Fibrous tissue. The fibrous base of the ulcer may contain vessels with thickened wall or with thrombosis<ref name="pathologyatlas">{{cite web | url=http://www.pathologyatlas.ro/Peptic%20ulcer.html| title=ATLAS OF PATHOLOGY|accessdate=2007-08-26}}</ref>


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Revision as of 23:56, 3 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ;Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]

Overview

A major causative factor (60% of gastric and 90% of duodenal ulcers) is chronic inflammation due to Helicobacter pylori that colonize the antral mucosa. The immune system is unable to clear the infection, despite the appearance of antibodies. Thus, the bacterium can cause a chronic active gastritis (type B gastritis), resulting in a defect in the regulation of gastrin production and gastrin secretion is increased. Gastrin stimulates the production of gastric acid by parietal cells. The acid erodes the mucosa and causes the ulcer. Another major cause is the use of NSAIDs The gastric mucosa protects itself from gastric acid with a layer of mucus, the secretion of which is stimulated by certain prostaglandins. NSAIDs block the function of cyclooxygenase 1 (cox-1), which is essential for the production of these prostaglandins.

Pathophysiology

Peptic ulcer occurs due to distruption of muscularis mucosa which occurs due to loss of defensive mechanism of gastric mucosa

Defensive mechanism of gastric mucosa Mucosal barrier

Diagram of alkaline Mucous layer in stomach with mucosal defense mechanisms
Source:Wikimedia Commons [5]

The two most important etiological factors in the development of PUD are:[6][7][8]

Role of Helicobacter pylori

Immunological response

Factors responsible for immunological response of Helicobacter pylori are :

 
 
 
 
 
 
 
 
Helicobacter pylori infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inflammatory response
secretes IL-8 ,IL-1b
 
 
 
 
Production of
alkaline ammonia
 
 
 
 
Production of urease
bacterial phospholipase A
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infux of neutophils and macrophages
release of lysosomal enzymes
leukotrienes (LT)and
reactive oxygen
 
 
 
 
inhibition of D-cells
leads to inappropriate release of somatostatin
and hypergastrinemia
 
 
 
 
Production of urease
,phospholipase
A and C
release toxic metabolities
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mucosal injury
 
 
 
 
 

Role of Helicobacter pylori in causing gastric ulcer

  • Colonzation:
    • The colonization of virulent CagA-positive Helicobacter pylori strains leads to the degeneration of surface epithelial cells
    • This degeneration results in increased exfoliation of surface epithelial cells
    • The exfoliation mediated compensatory cell proliferation leads to the movement of immature cells to the foveolae and surface
  • Immature cells leads to impaired mucin and bicarbonate production and the integrity of the mucous barrier may be compromised
  • All of above factors lead to activation of complement via the alternative pathway and the release of chemical mediators by mast cells and activated polymorphs may lead to microvascular disturbances and focal ischemic damage to the surface epithelium
  • Helicobacter pylori infection down-regulates E-cadherin expression in gastric epithelial cells which affect the resistance of the mucosa to acid attack
  • Decreased mucus production, release of chemical mediators and down-regulation of E- cadherin leads to mucosal damage leads to ulcer formation[18][19][20]

Role of Helicobacter pylori in causing duodenal ulcer

Role of NSAIDS

 
 
 
 
 
 
 
 
NSAIDs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
COX-1 inhibitor
 
 
 
 
Topical irritation
 
 
 
 
COX-2 inhibitor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Decreased blood flow
 
 
 
 
Epithelial damage
 
 
 
 
Inhibit
leucocyte adhesion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mucosal injury
 
 
 
 
 

Other factors

Other factors responsible for peptic ulcer disease:

Smoking

  • Chronic smoking leads to mucosal damage or deals healing of ulcer by following mechanism:[29]

Severe stress

Genetics

Associated Conditions

Gross Pathology

  • Gastric ulcers are most often localized on the lesser curvature of the stomach
  • Duodenal ulcers are more located at bulb of duodenum
  • Characteristic findings of a peptic ulcer on gross pathology include:
    • Round to oval
    • 2 to 4 cm diameter
    • Smooth base with perpendicular borders.
    • Parietal scarring with radial folds may be evident in the surrounding mucosa

Microscopic Pathology

  • A peptic ulcer is a mucosal defect produced by acid-pepsin aggression which penetrates the muscularis mucosae and muscularis propria.
  • There is increased plasma cells, neutrophilic infiltrate, villous blunting
  • The surface epithelium usually shows mucous cell (pseudopyloric) metaplasia
  • During the active phase, the base of the ulcer shows 4 zones:
    • Inflammatory exudate: polymorphonuclear infiltration which along with bacterial products stimulate the production of IL-8 and tumor necrosis factor alpha (TNF-α) and IL-1 released by macrophages in response to bacterial lipopolysaccharide
    • Fibrinoid necrosis
    • Granulation tissue
    • Fibrous tissue. The fibrous base of the ulcer may contain vessels with thickened wall or with thrombosis[37]

References

  1. ↑ Butler BD, Lichtenberger LM |title=Gastric mucosal barrier: hydrophobic lining to the lumen of the stomach |journal=Am. J. Physiol. |volume=244 |issue=5 |pages=G561–8 |year=1983 |pmid=6846549 |doi= |url=}}
  2. ↑ Clamp JR, Ene D (1989). "The gastric mucosal barrier". Methods Find Exp Clin Pharmacol. 11 Suppl 1: 19–25. PMID 2657286.
  3. ↑ Werther JL (2000). "The gastric mucosal barrier". Mt. Sinai J. Med. 67 (1): 41–53. PMID 10677782.
  4. ↑ Forssell H (1988). "Gastric mucosal defence mechanisms: a brief review". Scand. J. Gastroenterol. Suppl. 155: 23–8. PMID 3072665.
  5. ↑ By M•Komorniczak(http://creativecommons.org/licenses/by/3.0)
  6. ↑ url=http://www.nejm.org/doi/full/10.1056/NEJM199003293221307 |title=Pathogenesis of Peptic Ulcer and Implications for Therapy — NEJM |format= |work= |accessdate=}}
  7. ↑ 7.0 7.1 "Pathogenesis of Peptic Ulcer and Implications for Therapy — NEJM".
  8. ↑ Hawkey CJ (1999). "Personal review: Helicobacter pylori, NSAIDs and cognitive dissonance". Aliment. Pharmacol. Ther. 13 (6): 695–702. PMID 10383497.
  9. ↑ Kusters JG, van Vliet AH, Kuipers EJ (2006). "Pathogenesis of Helicobacter pylori infection". Clin. Microbiol. Rev. 19 (3): 449–90. doi:10.1128/CMR.00054-05. PMC 1539101. PMID 16847081.
  10. ↑ Huang JQ, Sridhar S, Hunt RH (2002). "Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: a meta-analysis". Lancet. 359 (9300): 14–22. doi:10.1016/S0140-6736(02)07273-2. PMID 11809181.
  11. ↑ url=http://www.nejm.org/doi/full/10.1056/NEJM199003293221307 |title=Pathogenesis of Peptic Ulcer and Implications for Therapy — NEJM |format= |work= |accessdate=}}
  12. ↑ Logan RP (1996). "Adherence of Helicobacter pylori". Aliment. Pharmacol. Ther. 10 Suppl 1: 3–15. PMID 8730255.
  13. ↑ Crabtree JE (1996). "Gastric mucosal inflammatory responses to Helicobacter pylori". Aliment. Pharmacol. Ther. 10 Suppl 1: 29–37. PMID 8730257.
  14. ↑ Ernst PB, Jin Y, Reyes VE, Crowe SE (1994). "The role of the local immune response in the pathogenesis of peptic ulcer formation". Scand. J. Gastroenterol. Suppl. 205: 22–8. PMID 7863238.
  15. ↑ Mobley HL (1996). "The role of Helicobacter pylori urease in the pathogenesis of gastritis and peptic ulceration". Aliment. Pharmacol. Ther. 10 Suppl 1: 57–64. PMID 8730260.
  16. ↑ Nilius M, Malfertheiner P (1996). "Helicobacter pylori enzymes". Aliment. Pharmacol. Ther. 10 Suppl 1: 65–71. PMID 8730261.
  17. ↑ Slomiany BL, Kasinathan C, Slomiany A (1989). "Lipolytic activity of Campylobacter pylori: effect of colloidal bismuth subcitrate (De-Nol)". Am. J. Gastroenterol. 84 (10): 1273–7. PMID 2801678.
  18. ↑ Kim JS, Jung HC, Kim JM, Song IS, Kim CY (1998). "Interleukin-8 expression by human neutrophils activated by Helicobacter pylori soluble proteins". Scand. J. Gastroenterol. 33 (12): 1249–55. PMID 9930387.
  19. ↑ Kimura K (1972). "Chronological transition of the fundic-pyloric border determined by stepwise biopsy of the lesser and greater curvatures of the stomach". Gastroenterology. 63 (4): 584–92. PMID 5077145.
  20. ↑ Malaty HM, Graham DY, Isaksson I, Engstrand L, Pedersen NL (2000). "Are genetic influences on peptic ulcer dependent or independent of genetic influences for Helicobacter pylori infection?". Arch. Intern. Med. 160 (1): 105–9. PMID 10632311.
  21. ↑ Wyatt JI, Rathbone BJ, Dixon MF, Heatley RV (1987). "Campylobacter pyloridis and acid induced gastric metaplasia in the pathogenesis of duodenitis". J. Clin. Pathol. 40 (8): 841–8. PMC 1141122. PMID 3654985.
  22. ↑ el-Omar EM, Penman ID, Ardill JE, Chittajallu RS, Howie C, McColl KE (1995). "Helicobacter pylori infection and abnormalities of acid secretion in patients with duodenal ulcer disease". Gastroenterology. 109 (3): 681–91. PMID 7657096.
  23. ↑ el-Omar E, Penman I, Dorrian CA, Ardill JE, McColl KE (1993). "Eradicating Helicobacter pylori infection lowers gastrin mediated acid secretion by two thirds in patients with duodenal ulcer". Gut. 34 (8): 1060–5. PMC 1374354. PMID 8174954.
  24. ↑ el-Omar EM, Penman ID, Ardill JE, Chittajallu RS, Howie C, McColl KE (1995). "Helicobacter pylori infection and abnormalities of acid secretion in patients with duodenal ulcer disease". Gastroenterology. 109 (3): 681–91. PMID 7657096.
  25. ↑ el-Omar E, Penman I, Dorrian CA, Ardill JE, McColl KE (1993). "Eradicating Helicobacter pylori infection lowers gastrin mediated acid secretion by two thirds in patients with duodenal ulcer". Gut. 34 (8): 1060–5. PMC 1374354. PMID 8174954.
  26. ↑ Borody TJ, George LL, Brandl S, Andrews P, Ostapowicz N, Hyland L, Devine M (1991). "Helicobacter pylori-negative duodenal ulcer". Am. J. Gastroenterol. 86 (9): 1154–7. PMID 1882793.
  27. ↑ Huang JQ, Sridhar S, Hunt RH (2002). "Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: a meta-analysis". Lancet. 359 (9300): 14–22. doi:10.1016/S0140-6736(02)07273-2. PMID 11809181.
  28. ↑ Holvoet J, Terriere L, Van Hee W, Verbist L, Fierens E, Hautekeete ML (1991). "Relation of upper gastrointestinal bleeding to non-steroidal anti-inflammatory drugs and aspirin: a case-control study". Gut. 32 (7): 730–4. PMC 1378985. PMID 1855677.
  29. ↑ Müller-Lissner SA (1986). "Bile reflux is increased in cigarette smokers". Gastroenterology. 90 (5 Pt 1): 1205–9. PMID 3956939.
  30. ↑ Räihä I, Kemppainen H, Kaprio J, Koskenvuo M, Sourander L (1998). "Lifestyle, stress, and genes in peptic ulcer disease: a nationwide twin cohort study". Arch. Intern. Med. 158 (7): 698–704. PMID 9554675.
  31. ↑ FakhreYaseri H, Shakaraby M, Bradaran HR, Soltani Arabshahi SK, Fakhre Yaseri AM (2014). "CagA and VacA genotypes in peptic ulcer disease and non-ulcer dyspepsia: a case-control study". Med J Islam Repub Iran. 28: 104. PMC 4301206. PMID 25664305.
  32. ↑ Jung DH, Kim JH, Chung HS, Park JC, Shin SK, Lee SK, Lee YC (2015). "Helicobacter pylori Eradication on the Prevention of Metachronous Lesions after Endoscopic Resection of Gastric Neoplasm: A Meta-Analysis". PLoS ONE. 10 (4): e0124725. doi:10.1371/journal.pone.0124725. PMC 4411104. PMID 25915048.
  33. ↑ Nakamura S, Sugiyama T, Matsumoto T, Iijima K, Ono S, Tajika M, Tari A, Kitadai Y, Matsumoto H, Nagaya T, Kamoshida T, Watanabe N, Chiba T, Origasa H, Asaka M (2012). "Long-term clinical outcome of gastric MALT lymphoma after eradication of Helicobacter pylori: a multicentre cohort follow-up study of 420 patients in Japan". Gut. 61 (4): 507–13. doi:10.1136/gutjnl-2011-300495. PMID 21890816.
  34. ↑ {{cite journal |vauthors=Suzuki T, Matsushima M, Masui A, Watanabe K, Takagi A, Ogawa Y, Shirai T, Mine T |title=Effect of Helicobacter pylori eradication in patients with chronic idiopathic thrombocytopenic purpura-a randomized controlled trial |journal=Am. J. Gastroenterol. |volume=100 |issue=6 |pages=1265–70 |year=2005 <ref name="pmid18945961">Stasi R, Sarpatwari A, Segal JB, Osborn J, Evangelista ML, Cooper N, Provan D, Newland A, Amadori S, Bussel JB (2009). "Effects of eradication of Helicobacter pylori infection in patients with immune thrombocytopenic purpura: a systematic review". Blood. 113 (6): 1231–40. doi:10.1182/blood-2008-07-167155. PMID 18945961.
  35. ↑ {{cite journal |vauthors=Neunert C, Lim W, Crowther M, Cohen A, Solberg L, Crowther MA |title=The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia |journal=Blood |volume=117 |issue=16 |pages=4190–207 |year=2011 |
  36. ↑ name="urlAmerican Journal of Gastroenterology - ACG Clinical Guideline: Treatment of Helicobacter pylori Infection">"American Journal of Gastroenterology - ACG Clinical Guideline: Treatment of Helicobacter pylori Infection".
  37. ↑ "ATLAS OF PATHOLOGY". Retrieved 2007-08-26.


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