Reduced long-term survival following major peptic ulcer haemorrhage
Sir
This study (Br J Surg 1997; 84: 265-8) draws attention to the consequences (non-fatal and fatal peptic ulcer recurrence) of allowing the preoccupation with surgical procedures that alleviate life-threatening complications to dominate clinical decision-making, to the exclusion of strategies (medical or surgical) that modify favourably the natural history of peptic ulcer disease. The recognition that the peptic ulcer diathesis is one characterized by a relapsing course, even in the modern therapeutic era', mandates the implementation of strategies to reduce the recurrence rate, regardless of the immediate success of measures such as endoscopic haemostatic therapy. The prophylactic range includes, respectively, eradication of Helicobacter pylori in patients with proven infection2 and longterm use of antisecretory therapy in those who are H. pylorinegative'. A case could even be made for a 'belt and braces' strategy, using both treatments, in high-risk subgroups such as the elderly and those with serious co-morbidity. Even after successful eradication of H. pylori 4-6 per cent of peptic ulcers recur4 and sometimes with haemorrhagic sequelae2. For those with co-morbid disorders necessitating co-prescription of nonsteroidal anti-inflammatory drugs (NSAIDs), misoprostol is preferable to H2-receptor antagonists as it protects the duodenum (the only site protected by ranitidine)' and the stomach', the site most favoured by NSAID-related ulcers". For those intolerant of the optimum recommended dose of 200pg four times daily, modest prophylactic benefit, with significantly fewer side-effects, can still be obtained with a 50 per cent dose reduction'.