Disease Basis

Since the beginning of the twentieth century, the concept of 'no acid-no ulcer' led to various measures to reduce acid secretion in the GI tract. These measures were, in the absence of drugs targeted to the stomach, inevitably surgical. Total or partial gastrectomy was introduced by Billroth, and, with the recognition that vagal stimulation was responsible in large measure for the stimulation of acid secretion, this somewhat dramatic procedure was followed by vagotomy and highly selective vagotomy.12,13 These surgical measures were relatively effective for PUD, albeit accompanied by the risks associated with open abdominal surgery. With the recognition of GERD as a major affliction and also that abnormal reflux was responsible, measures such as fundoplication were introduced, and still are used today, but usually by laparoscopic approaches. In PUD, modern medications, such as the H2 receptor antagonists or PPIs, greatly reduced the need for surgical intervention, as is the case also for treatment of GERD. The recognition of H. pylori as being required for most PUD resulted in eradication regiments that, for the first time, were able to cure, not only treat, this disorder. Nevertheless, either because of lack of appropriate diagnosis or timely access to medical care, or because of the excessive use of NSAIDs, there is still often hemorrhage or even perforation of the stomach or duodenum that is treated on an emergency basis, either surgically or by endoscopic cautery of the bleeding vessel. Hence, although advances in treatment have been truly remarkable, acid-related GI disease is still a major phenomenon throughout the world. With modern diagnostic approaches, symptoms are not always associated with visible findings, and nonulcer dyspepsia (NUD) remains a controversial topic, with the role of acid, H. pylori, and afferent neural hypersensitivity being considered causal. Up to 50% of NUD can be improved by acid suppression.

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