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OESO©2015
 
Volume: The Esophageal Mucosa
Chapter: Epidemiology
 

Is there a relationship between esophagitis and duodenal ulcer?

G. Champault, J.C. Kikassa (Paris)

Although duodenal ulcer disease (DUD) and acid reflux esophagitis occur concurrently relatively frequently (10-15%) [1,2], the reasons for this are not fully understood [3]. A retrospective study of the mutual incidence of these two disorders, which are both caused by damaging acid action, was carried out in order to assess the therapeutic consequences.

Patients and Methods

Patients

All subjects who underwent esogastroduodenal endoscopy during 1992 in the Gastrointestinal Endoscopy department (Prof J.P. Ferrier) of the Jean Verdier Hospital in Bondy.

Selection criteria: symptomatic patients with:

- isolated duodenal lesions;

- isolated esophageal lesions;

- both these types of lesions;

- neither of these types of lesions. Exclusion criteria:

- patients under 18 years of age;

- hemorrhage of the upper or lower gastrointestinal tract;

- patients known to have cirrhosis of the liver;

- esophageal-gastric varices;

- patients surgically treated for duodenal ulcer or gastroesophageal reflux (GER);

- endoscopic examination after medical treatment for duodenal ulcer or esophagitis;

- endoscopic gastric lesions: ulceration, inflammation, tumor.

Methods

The study involved retrospective analysis of endoscopy reports. The following lesions were taken into account:

- duodenal lesions:

- acute inflammation of the duodenum;

- superficial ulcerations;

- newly formed ulcers; - chronic ulcers;

- esophageal lesions (Savary's classification):

- erythematous lesions;

- hemorrhagic lesions;

- ulceration;

- stenosing lesion or ulcer.

Results

A total of 1,600 patients satisfied the selection criteria. Their mean age was 39 ± 17 years and the sex ratio was 3:1.

Lesions: distribution

Duodenal lesions

- 274 patients (17%) had duodenal lesions comprising:

- 164 cases of duodenal inflammation (59%);

- 110 ulcers (6.8% of the study population) of which 92 were newly formed and 18 were chronic (18.8% of duodenal lesions).

Esophageal lesions

- 253 patients (15.8%) had esophageal lesions:

- 170 cases of stage I esophagitis;

- 38 cases of stage II esophagitis (2% of the study population);

- 45 cases of stage III and IV esophagitis (3% of the study population); 89 patients (5.6%) had both esophageal and duodenal lesions.

Lesions: combination

Table 1. .Incidence of esophagitis in patients with duodenal lesions

Duodenal lesions

N

Esophagitis

%

Inflammation

164

22

13.4

Ulceration

110

67

60.9

Newly formed

92

51

55.4

Chronic

18

16

88.8

Table 2. .Incidence of duodenal lesions in patients with esophagitis

Esophagitis

N

Duodenal lesion

%

Stage I

170

26

15.2

Stages II and III

38

21

55.2

Stage IV

45

32

71.1

Stenosis

4

3

75

Barrett's esophagus

17

12

70

• Ulcers

24

17

70

Discussion

This study confirmed the results published in the literature [3,4], especially with regard to the reciprocal incidence of the most severe effects of these two disorders. Although the incidence of esophagitis was only 13.4%, among subjects with superficial acute duodenal lesions, it was significantly greater among patients with proven ulcer disease (55%, p = 0.001) and especially among those with chronic ulcers (88.8%, p = 0.0001). The same was true for esophagitis: while (mostly superficial) duodenal lesions were found in 15.2% of patients with mild esophagitis, the incidence of duodenal lesions increased to 55 and 77% in those patients in which the disease was at a more advanced stage. This increase was statistically significant (p = 0.001). In contrast, however, there was no significant difference between the patients exhibiting different forms of advanced esophageal lesions (stenosis or ulceration; 75 vs. 70%), including Barrett's esophagus (70%).

In this study only 89 patients, 5.5% of the global study population, were suffering from both a severe form of esophagitis and chronic duodenal ulcer indicating that such cases are rare. It would appear that the risk of having both types of lesions together increases with increasing severity of one or other of the lesions. This raises interesting therapeutic problems, at both medical and surgical levels.

It appears that therapeutic measures must be taken whose effects are of immediate onset and long-lived. Despite the success of drug therapy, and especially that based on the proton pump inhibitors (PPI) [4], this combination of disorders requires an initial treatment of at least 8 weeks to heal the lesions (90% of esophageal lesions). Subsequently, maintenance treatment with H2 receptor antagonists [5] should be given to consolidate the response and to reduce the likelihood of complications in these patients at risk. Surgical treatment also presents a problem, especially whether or not to combine antireflux surgery with vagotomy [6]. This procedure, which can now be carried out by laparoscopic route, would seem to be the best solution in men under 50 and women under 65 years of age, in view of its effectiveness and an estimated annual recurrence rate of 1.5%.

Conclusions

If there is a relation between esophagitis and duodenal ulcer, it only really concerns the severe forms of the disease. Patients with this pathological combination (5.6%) present an interesting therapeutic problem, although surgical treatment, especially by laparoscopy, would seem a good alternative to medical treatment.

References

1. Lahoti D, Misra SP, Malhotra V, Vij JC. Relationship of heartburn with histopathological changes in esophagus and stomach in patients with duodenal ulcer. J Gastroenterol 1991;10(2):54-55.

2. Stol DW, Murphy GM, Collis JL. Duodenogastric reflux acid and secretion in patients with symptomatic hiatal hernia. Scand J Gastroenterol I974;9:97-101.

3. Hirschowitz BI. A critical analysis with appropriate controls of gastric acid and pepsin secretion in clinical oesophagitis. Gastroenterology 1991;101:1149-1158.

4. Walan A The clinical utility and safety of omeprazole. Scand J Gastroenterol 1989;(suppl 166):140-144.

5. Bender SW. Therapie mit H2 rezeptor antagonisten im kindersalter. Einsatz von ranitidin über ulcers duodeni, ventriculi und refluxoesophagitis. Fortsc d Medizin 1992;l10(33):629-632.

6. Chernousov AF, Rishko VV, Bopolskii PM, Efendiev VM. Combined surgical treatment of duodenal ulcer and reflux esophagitis. Vest Khirurg Imen 1989;142(3):34-38.


Publication date: May 1994 OESO©2015