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The most common symptom of a peptic ulcer is abdominal pain. </div> <div> It wasn't too long ago that lifestyle factors, such as a love of spicy foods or a stressful job, were thought to be at the root of most peptic ulcers. Doctors now know that a bacterial infection or some medications — not stress or diet — cause most peptic ulcers. </div> <div> Peptic ulcers are common, affecting as many as 10 percent of Americans at some point in their lives. The good news is that successful treatment of peptic ulcers is possible. </div> <div> Symptoms</div> <div> Burning pain is the most common peptic ulcer symptom. The pain is caused by the ulcer and is aggravated by stomach acid coming in contact with the ulcerated area. The pain typically may: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Be felt anywhere from your navel up to your breastbone </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Last from a few minutes to several hours </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Be worse when your stomach is empty </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Flare at night </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Often be temporarily relieved by eating certain foods that buffer stomach acid or by taking an acid-reducing medication </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Disappear and then return for a few days or weeks </div> <div> Less often, ulcers may cause severe signs or symptoms such as: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The vomiting of blood — which may appear red or black </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dark blood in stools or stools that are black or tarry </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nausea or vomiting </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Unexplained weight loss </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Appetite changes </div> <div> <B>When to see a doctor </B></div> <div> An ulcer isn't something that you should treat on your own, without a doctor's help. Over-the-counter antacids and acid blockers may relieve the gnawing pain, but the relief is short-lived. If you have signs or symptoms of an ulcer, see your doctor for treatment. </div> <div> Causes</div> <bR> <div> Depending on their location, peptic ulcers have different names: </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gastric ulcer.</B> This is a peptic ulcer that occurs in your stomach. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Duodenal ulcer.</B> This type of peptic ulcer develops in the first part of the small intestine (duodenum). </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Esophageal ulcer.</B> An esophageal ulcer is usually located in the lower section of your esophagus. It's often associated with chronic gastroesophageal reflux disease (GERD). </div> <div> <B>The culprit in most cases</B> </div> <div> Although stress and spicy foods were once thought to be the main causes of peptic ulcers, doctors now know that the cause of most ulcers is the corkscrew-shaped bacterium Helicobacter pylori (H. pylori). </div> <div> H. pylori lives and multiplies within the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, H. pylori causes no problems. But sometimes it can disrupt the mucous layer and inflame the lining of your stomach or duodenum, producing an ulcer. </div> <div> H. pylori is a common gastrointestinal infection. In the United States, one in five people younger than 30 and half the people older than 60 are infected. Although it's not clear exactly how H. pylori spreads, it may be transmitted from person to person by close contact, such as kissing. People may also contract H. pylori through food and water. </div> <div> H. pylori is the most common, but not the only, cause of peptic ulcers. Besides H. pylori, other causes of peptic ulcers, or factors that may aggravate them, include: </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Regular use of pain relievers.</B> Nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate or inflame the lining of your stomach and small intestine. These medications, which are available both by prescription and over-the-counter, include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve), ketoprofen and others. To help avoid digestive upset, take NSAIDs with meals. If you have been diagnosed with an ulcer, make sure your doctor knows this when prescribing any pain reliever. Other medications that contain NSAIDs are Alka-Seltzer and bismuth subsalicylate (Pepto-Bismol, others). Unfortunately, some people take these medications for symptoms of peptic ulcer, but they can make the condition worse. Other prescription medications that can also lead to ulcers include medications used to treat osteoporosis called bisphosphonates (Actonel, Fosamax and others). </div> <div> NSAIDs inhibit production of an enzyme (cyclooxygenase) that produces prostaglandins. These hormone-like substances help protect your stomach lining from chemical and physical injury. Without this protection, stomach acid can erode the lining, causing bleeding and ulcers. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Smoking.</B> Nicotine in tobacco increases the volume and concentration of stomach acid, increasing your risk of an ulcer. Smoking may also slow healing during ulcer treatment. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Excessive alcohol consumption.</B> Alcohol can irritate and erode the mucous lining of your stomach and increases the amount of stomach acid that's produced. It's uncertain, however, whether this alone can progress into an ulcer or if it just aggravates the symptoms of an existing ulcer. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Stress.</B> Although stress per se isn't a cause of peptic ulcers, it's a contributing factor. Stress may aggravate symptoms of peptic ulcers and, in some cases, delay healing. You may undergo stress for a number of reasons — an emotionally disturbing circumstance or event, surgery, or a physical trauma, such as a burn or other severe injury. </div> <div> Complications</div> <div> Left untreated, peptic ulcers can result in: </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Internal bleeding. </B>Bleeding can occur as slow blood loss that leads to anemia or as severe blood loss that may require hospitalization or a blood transfusion. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Infection. </B>Peptic ulcers can eat a hole through the wall of your stomach or small intestine, putting you at risk of serious infection of your abdominal cavity (peritonitis). </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Scar tissue.</B> Peptic ulcers can also produce scar tissue that can obstruct passage of food through the digestive tract, causing you to become full easily, to vomit and to lose weight. </div> <div> Preparing for your appointment</div> <div> You'll probably first see your family doctor or a general practitioner. However, he or she may then refer you to a gastroenterologist for further diagnosis and treatment. </div> <div> It's a good idea to be well prepared for your appointment so that you have enough time to cover everything you want to with your doctor. Here's some information to help you get ready for your appointment, and what you can expect from your doctor. </div> <div> <B>What you can do</B> </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Be aware of any pre-appointment restrictions.</B> At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet. Certain medications can affect peptic ulcer tests, so your doctor may want you to stop taking them, and he or she may be able to suggest alternatives to these drugs. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Write down any symptoms you're experiencing,</B> including any that may seem unrelated to the reason for which you scheduled the appointment. It's also a good idea to keep written track of your symptoms as well as the food you're eating. People with peptic ulcers often experience more symptoms when their stomachs are empty. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Write down key personal information,</B> including any major stresses or recent life changes. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Make a list of all medications,</B> as well as any vitamins or supplements, that you're taking. It's especially important to note any NSAID use and the usual dose that you take. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Write down questions to ask your doctor.</B> </div> <div> Preparing a list of questions ahead of time will help you make the most of your limited time with your doctor. List your questions from most important to least important in case time runs out. For peptic ulcers, some basic questions to ask your doctor include: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">What's the most likely cause of my symptoms? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Are there other possible causes for my symptoms? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">What kinds of tests do I need, and how do I need to prepare for them? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Is my condition likely temporary or chronic? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">What treatment do you recommend? How quickly will I start to feel better? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">What if my symptoms don't improve? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">What are the alternatives to the primary approach that you're suggesting? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Are there any dietary restrictions that I need to follow? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Is there a generic or over-the-counter alternative to the medicine you're prescribing me? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">What caused me to develop this ulcer? </div> <div> In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something. </div> <div> <B>What to expect from your doctor</B> </div> <div> Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to cover. Your doctor may ask: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When did you first begin experiencing symptoms? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Have your symptoms been continuous, or intermittent? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">How severe are your symptoms? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Are your symptoms worse when you're hungry? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Does anything seem to improve your symptoms? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">What, if anything, appears to worsen your symptoms? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Do you take pain relievers? If yes, how often? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Do you feel nauseated or have you been vomiting? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Have you ever vomited blood or black material? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Have you noticed blood in your stool or black stools? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">What, if anything, have you been taking to relieve your symptoms? </div> <div> <B>What you can do in the meantime </B></div> <div> While you're waiting to see your doctor, avoiding smoking, alcohol, spicy foods and stress may help lessen your discomfort. If you take NSAIDs for pain relief, try switching to acetaminophen (Tylenol, others). Additionally, for short-term relief, you can also take over-the-counter antacids or acid-blocking medications. </div> <div> Tests and diagnosis</div> <div> In order to detect an ulcer, you may have to undergo diagnostic tests, such as: </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Blood test.</B> This test checks for the presence of H. pylori antibodies. A disadvantage of this test is that it sometimes can't differentiate between past exposure and current infection. Additionally, a false-negative is possible if you've recently been taking certain drugs, such as antibiotics or proton pump inhibitors. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Breath test.</B> This procedure uses a radioactive carbon atom to detect H. pylori. For the test, you drink a small glass of clear, tasteless liquid. The liquid contains radioactive carbon as part of a substance (urea) that will be broken down by H. pylori. Less than an hour later, you blow into a bag, which is then sealed. If you're infected with H. pylori, your breath sample will contain the radioactive carbon in the form of carbon dioxide. </div> <div> The advantage of the breath test is that it can monitor the effectiveness of treatment used to eradicate H. pylori, detecting whether the bacteria have been killed or eradicated. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Stool antigen test.</B> This test checks for H. pylori in stool samples. It's useful both in helping to diagnose H. pylori infection and in monitoring the success of treatment. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Upper gastrointestinal (upper GI) X-ray.</B> This test outlines your esophagus, stomach and duodenum. During the X-ray, you swallow a white, metallic liquid (containing barium) that coats your digestive tract and makes an ulcer more visible. An upper GI X-ray can detect some ulcers, but not all. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Endoscopy.</B> This procedure may follow an upper GI X-ray if the X-ray suggests a possible ulcer, or your doctor may perform endoscopy first. In this more sensitive procedure, a long, narrow tube with an attached camera is threaded down your throat and esophagus into your stomach and duodenum. With this instrument, your doctor can view your upper digestive tract and identify an ulcer. Your doctor will perform this test if you have other signs or symptoms, such as difficulty swallowing, weight loss, vomiting (particularly vomiting red or black material that looks like coffee grounds), black stools or anemia. </div> <div> If your doctor detects an ulcer, he or she may remove small tissue samples (biopsy) near the ulcer. These samples are examined under a microscope to rule out cancer. A biopsy can also identify the presence of H. pylori in your stomach lining. Depending on where the ulcer is found, your doctor may recommend a repeat endoscopy after two to three months to confirm that the ulcer is healing. </div> <div> Treatments and drugs</div> <div> Because many ulcers stem from H. pylori bacteria, doctors use a two-pronged approach to peptic ulcer treatment: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Kill the bacteria. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Reduce the level of acid in your digestive system to relieve pain and encourage healing. </div> <div> Accomplishing these two goals requires the use of at least two, and sometimes three or four, of the following medications: </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antibiotic medications.</B> Doctors use combinations of antibiotics to treat H. pylori because one antibiotic alone isn't always sufficient to kill the organism. For the treatment to work, follow your doctor's instructions precisely. Antibiotics prescribed for treatment of H. pylori include amoxicillin (Amoxil), clarithromycin (Biaxin) and metronidazole (Flagyl). Combination drugs that include two antibiotics together with an acid suppressor or cytoprotective agent (Helidac, Prevpac) have been designed specifically for the treatment of H. pylori infection. You'll likely need to take antibiotics for two weeks, depending on their type and number. Other medications prescribed along with antibiotics generally are taken for a longer period. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acid blockers.</B> Acid blockers — also called histamine (H-2) blockers — reduce the amount of hydrochloric acid released into your digestive tract, which relieves ulcer pain and encourages healing. Acid blockers work by keeping histamine from reaching histamine receptors. Histamine is a substance normally present in your body. When it reacts with histamine receptors, the receptors signal acid-secreting cells in your stomach to release hydrochloric acid. Available by prescription or over-the-counter (OTC), acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid). </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antacids.</B> Your doctor may include an antacid in your drug regimen. An antacid may be taken in addition to an acid blocker or in place of one. Instead of reducing acid secretion, antacids neutralize existing stomach acid and can provide rapid pain relief. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Proton pump inhibitors.</B> Another way to reduce stomach acid is to shut down the "pumps" within acid-secreting cells. Proton pump inhibitors reduce acid by blocking the action of these tiny pumps. These drugs include the prescription and over-the-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex) and esomeprazole (Nexium). The drug pantoprazole (Protonix) can be taken orally or administered intravenously in the hospital. Doctors frequently prescribe proton pump inhibitors to promote the healing of peptic ulcers. If you're admitted to the hospital with a bleeding ulcer, taking intravenous proton pump inhibitors decreases the chance that bleeding will recur. Proton pump inhibitors also appear to inhibit H. pylori. However, long-term use of proton pump inhibitors, particularly at high doses, may increase your risk of hip fracture. Ask your doctor if you need a calcium supplement while taking these medications. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cytoprotective agents. </B>In some cases, your doctor may prescribe these medications that help protect the tissues that line your stomach and small intestine. They include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec). Another nonprescription cytoprotective agent is bismuth subsalicylate (Pepto-Bismol). </div> <div> If H. pylori isn't identified in your system, then it's likely that your ulcer is due to NSAIDs — which you should stop using, if possible — or acid reflux, which can cause esophageal ulcers. In both cases, your doctor will try to reduce acid levels — through use of acid blockers, antacids or proton pump inhibitors — and may also have you use cytoprotective drugs. </div> <div> <B>Ulcers that fail to heal</B></div> <div> Peptic ulcers that don't heal with treatment are called refractory ulcers. There are many reasons why an ulcer may fail to heal. These reasons may include: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Not taking medications according to directions. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The fact that some types of H. pylori are resistant to antibiotics. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Regular use of tobacco. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Regular use of alcohol. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs). Sometimes the problem is accidental: People may be unaware that a medication they're taking contains an NSAID. </div> <div> Less often, refractory ulcers may be a result of: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Extreme overproduction of stomach acid, such as occurs in Zollinger-Ellison syndrome </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">An infection other than H. pylori </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Stomach cancer </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Other diseases, including cirrhosis and chronic obstructive pulmonary disorder (COPD) </div> <div> Treatment for refractory ulcers generally involves eliminating factors that may interfere with healing, along with stronger doses of ulcer medications. Sometimes, additional medications may be included. Surgery to help heal an ulcer is necessary only when the ulcer doesn't respond to aggressive drug treatment. </div> <div> Lifestyle and home remedies</div> <div> Before the discovery of H. pylori, doctors often advised people with ulcers to eat a restricted diet and reduce the amount of stress in their lives. Now that food and stress have been eliminated as direct causes of ulcers, these factors are no longer of as much importance. </div> <div> However, while an ulcer is healing, it's still advisable to watch what you eat and to control stress. Acidic or spicy foods may increase ulcer pain. The same is true for stress because stress may increase acid. If stress is severe, it may delay the healing of an ulcer. </div> <div> Your doctor may also give you these helpful suggestions: </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Don't smoke.</B> Smoking may interfere with the protective lining of the stomach, making your stomach more susceptible to the development of an ulcer. Smoking also increases stomach acid. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Limit or avoid alcohol.</B> Excessive use of alcohol can irritate and erode the mucous lining in your stomach and intestines, causing inflammation and bleeding. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Avoid nonsteroidal anti-inflammatory drugs (NSAIDs).</B> If you use pain relievers regularly, use acetaminophen (Tylenol, others). </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Control acid reflux.</B> If you have an esophageal ulcer — usually associated with acid reflux — you can take several steps to help manage acid reflux. These include avoiding spicy and fatty foods, avoiding reclining after meals, raising the head of your bed and reducing your weight. Avoiding smoking, alcohol and NSAIDs also may help to control acid reflux. </div> <div> <U>By Mayo Clinic Staff</U><FONT SIZE="3" COLOR="#660099" FACE="Arial" > </FONT></div> <div> Jan. 6, 2009 </div> <div> © 1998-2009 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Reliable tools for healthier lives," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. </div> <div> DS00242 </div> <bR> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="597" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 25 ><NOBR><div>  <A NAME="gastroesophageal_reflux_disease__gerd_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><FONT SIZE="4" COLOR="#660099" FACE="Arial" ><B>Gastroesophageal Reflux Disease (GERD)</B></FONT> </div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="148"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="25" ALIGN="bottom" WIDTH="148" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 19 WIDTH="434"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="434" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER ROWSPAN=21 WIDTH="148"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="148" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 414 WIDTH="434"><div> GERD is a common condition that affects from 5% to 7% of the population. The most common symptom of GERD is chronic heartburn, but it's not the only symptom.</div> <bR> <div> Other symptoms of GERD include: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Belching </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Chronic sore throat </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Difficulty or pain when swallowing </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Waterbrash (sudden excess of saliva) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hoarseness </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sour taste in the mouth </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bad breath </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Inflammation of the gums </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Erosion of tooth enamel (the surface of the teeth)</div> <div> <I>NOTE: chest pain is also a symptom of heartburn. However, it is often difficult to differentiate chest pain due to heartburn/GERD and chest pain due to heart disease. Therefore, be sure to get all chest pain evaluated IMMEDIATELY by a health care professional.</I></div> <bR> <div> Sometimes, there are no symptoms and GERD is only diagnosed when complications (see below) arise. </div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 19 WIDTH="434"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="434" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="10"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="38" ALIGN="bottom" WIDTH="10" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER COLSPAN=4 WIDTH="423"><bR> <div> How is GERD diagnosed?</div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 19 WIDTH="434"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="434" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 208 WIDTH="10"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="208" ALIGN="bottom" WIDTH="10" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER COLSPAN=4 WIDTH="423"><bR> <div> First your doctor will review your symptoms with you and do a complete physical examination.</div> <bR> <div> If he or she believes that you have GERD, usually you will be given a trial run of GERD medications (most often proton-pump inhibitors such as Nexium, Aciphex, Prilosec, Prevacid, and Protonix) for two weeks to see if you experience relief.</div> <bR> <div> In some instances, further testing, such as pH testing may be needed to aid in diagnosis.</div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 19 WIDTH="434"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="434" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="10"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="38" ALIGN="bottom" WIDTH="10" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER COLSPAN=4 WIDTH="423"><bR> <div> What causes GERD?</div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 19 WIDTH="434"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="434" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 398 WIDTH="10"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="398" ALIGN="bottom" WIDTH="10" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER COLSPAN=4 WIDTH="423"><bR> <div> There is no known single cause of GERD. What we know is that GERD occurs when the normal defenses of the esophagus are overwhelmed by acid refluxing into it from the stomach.</div> <bR> <div> Normally stomach acid is kept in the stomach by a muscular valve between it and the esophagus called the lower esophageal sphincter. If that valve is faulty for any reason, reflux occurs.</div> <bR> <div> Factors that may contribute to GERD include smoking, being overweight or pregnant, the use of certain medications and consumption of GERD-aggravating foods (which vary on an individual basis).</div> <bR> <div> The symptoms of GERD are a result of the damage caused by stomach acid that has entered the esophagus (heartburn, belching) or higher into the throat (hoarseness, sore throat) or even into the mouth (sour taste in the mouth, erosion of tooth enamel).</div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 19 WIDTH="434"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="434" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 19 WIDTH="434"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="434" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="10"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="38" ALIGN="bottom" WIDTH="10" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER COLSPAN=4 WIDTH="423"><bR> <div> How is GERD treated?</div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 19 WIDTH="434"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="434" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 57 WIDTH="10"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="57" ALIGN="bottom" WIDTH="10" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER COLSPAN=4 WIDTH="423"><bR> <div> GERD is usually treated with a combination of prescription medications and lifestyle changes.</div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 19 WIDTH="434"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="434" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 19 WIDTH="434"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="434" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 WIDTH="10"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="38" ALIGN="bottom" WIDTH="10" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER COLSPAN=4 WIDTH="423"><bR> <div> What happens if GERD goes untreated?</div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 19 WIDTH="434"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="434" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 227 WIDTH="10"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="227" ALIGN="bottom" WIDTH="10" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER COLSPAN=4 WIDTH="423"><bR> <div> Besides the obvious affect on quality of life, untreated GERD can lead to some serious complications. They include: </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Esophagitis.</B> This is an irritation and inflammation of the lining of the esophagus caused by stomach acid. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dysphagia.</B> Over time, untreated GERD causes difficulty swallowing or dysphagia. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Barrett's esophagus.</B> The chronic exposure to stomach acid can cause changes in the cells of the esophagus that may be precancerous. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Esophageal cancer.</B> Years of exposure to stomach acid may cause cancer of the esophagus.</div> </tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=5 HEIGHT= 19 WIDTH="434"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="434" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <div> For a complete guide to heartburn for your patient visit <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>WebMD Health</U></FONT> </div> <div> Reviewed by the doctors at the Cleveland Clinic Department of Gastroenterology & Hepatology. </div> <div> Edited by Cynthia Haines, MD, WebMD, January 2006.</div> <bR> <div> SOURCES: American Gastroenterology Association. International Foundation for Functional Gastrointestinal Disorders, Inc. The National Institute of Diabetes and Digestive and Kidney Diseases. </div> <div> Copyright © 2006, <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>The Cleveland Clinic</U></FONT>.</div> <bR> <bR> <div> <B> <A NAME="28_tips_for_nighttime_heartburn_relief"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>28 Tips for Nighttime Heartburn Relief</B></div> <div> Stop suffering heartburn symptoms at night. Get relief with these food, drink, and lifestyle tips. </div> <div> By <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Wendy C. Fries</U></FONT> </div> <div> WebMD Feature </div> <div> Reviewed by <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Brunilda Nazario, MD</U></FONT> </div> <div> A bitter taste in the mouth, a chronic cough, sore throat, fatigue ... if you're waking every morning with these symptoms of nighttime heartburn, you want relief.</div> <div> Millions experience heartburn and the more serious condition gastroesophageal reflux disease (GERD) daily. And research shows that nighttime heartburn affects nearly four out of five of heartburn sufferers -- disturbing sleep and impairing their ability to function the next day.</div> <div> If you're one of these people, find nighttime heartburn relief with these simple lifestyle, exercise, and food tips.</div> <div> <B>12 Food and Drink Tips for Nighttime Heartburn Relief</B></div> <div> Prevent heartburn by limiting acidic foods, such as grapefruit, oranges, tomatoes, or vinegar </div> <div> Spicy foods giving you heartburn? Cut back on pepper or chilies. </div> <div> Don't lie down for two to three hours after you eat. When you are sitting up, gravity helps drain food and stomach acid into your stomach. </div> <div> Enjoy lean meats and nonfatty foods. Greasy foods (like French fries and cheeseburgers) can trigger heartburn. </div> <div> Want to avoid GERD symptom triggers? You may want to cut back on chocolate, mint, citrus, tomatoes, pepper, vinegar, catsup, and mustard. </div> <div> Avoid drinks that can trigger reflux, such as alcohol, drinks with caffeine, and carbonated drinks. </div> <div> Size matters: Eat smaller meals and you may avoid triggering GERD symptoms. </div> <div> Enjoy an after-work drink? You may want to turn to teetotaling: Alcohol can relax the esophageal sphincter, worsening GERD. </div> <div> Crazy about colas? It may be time to cut back. Colas can be related to reflux and to GERD symptoms. </div> <div> Keep heartburn at bay: Don't eat too quickly! Try putting your fork down between bites. </div> <div> Avoid snacking at bedtime. Eating close to bedtime can trigger heartburn symptoms. </div> <div> Reduce your nighttime heartburn risk: Eat meals two to three hours before sleep. </div> <div> <B>16 Lifestyle Tips for Nighttime Heartburn Relief</B></div> <div> Steer clear of tight clothes. Tight belts, waistbands, and pantyhose can press on your stomach, triggering heartburn. </div> <div> Strive for a less stressful life. Stress may increase stomach acids, boosting heartburn symptoms. </div> <div> Heavy? Try losing weight. The pressure of excess weight increases the chance stomach acid will backup into the esophagus. </div> <div> Popping antacids more than once a week? You may have GERD, not heartburn, and need more aggressive treatment. </div> <div> Try chewing gum at night. This can boost the production of saliva, which neutralizes stomach acid. </div> <div> Not all "trigger" foods cause GERD symptoms in everyone. Keep track of your symptoms to find <I>your</I> personal triggers. </div> <div> Pregnant? You may experience heartburn or GERD. Talk to your doctor about finding relief. </div> <div> Heartburn worse after exercise? Drink plenty of water. It helps with hydration and digestion. </div> <div> Untreated GERD can radically increase your risk of esophageal cancer. But reflux <I>can</I> be managed. Talk with your doctor. </div> <div> Try keeping a diary or heartburn log to keep track of activities that might trigger incidents. </div> <div> A full tummy can mean a night full of heartburn pain. Wait at least 2-3 hours after you eat before going to bed. </div> <div> Wait for your workout. Don't want to trigger heartburn? Wait at least two hours after a meal before exercising. </div> <div> Nicotine can cause your esophageal sphincter to relax. If you smoke, kick the habit. </div> <div> Some medicines can worsen reflux. Talk with your doctor about alternatives. </div> <div> Use blocks or bricks under the bedpost to raise the head of your bed 6 inches so you can sleep with head and chest elevated. You can also try a wedge pillow. </div> <div> Bend with your knees. Bending over at the waist tends to increase reflux symptoms. </div> <bR> <bR> <div>  <A NAME="natalizumab_effective_for_active"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Natalizumab Effective for Active Crohn's Disease CME </div> <div> <B>News Author: David Douglas</B></div> <div> <B>CME Author: Laurie Barclay, MD</B> </div> <div> Complete author <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>affiliations and disclosures, and other CME information</U></FONT>, are available at the end of this activity.</div> <div> <B>Release Date: June 8, 2007</B>; Valid for credit through June 8, 2008 </div> <div> <B>Credits Available</B></div> <div> <B>Physicians</B> - maximum of 0.25 <I>AMA PRA Category 1 Credit(s)™</I> for physicians;</div> <div> <B>Family Physicians</B> - up to 0.25 AAFP Prescribed credit(s) for physicians </div> <div> All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.</div> <div> Physicians should only claim credit commensurate with the extent of their participation in the activity.</div> <bR> <div> June 8, 2007 — Natalizumab, a humanized immunoglobulin G4 monoclonal antibody targeting a-4 integrins, is more effective than placebo in treatment of certain patients with Crohn's disease and active inflammation.</div> <div> "These studies confirm that natalizumab can treat active Crohn's disease patients," lead author Dr. Stephan R. Targan told Reuters Health. "If approved by the FDA, it will offer patients an alternative therapy with a different mechanism of action from therapies targeted to tumor necrosis factor."</div> <div> In the May issue of <I>Gastroenterology</I>, Dr. Targan of Cedars Sinai Medical Center, Los Angeles and colleagues report the results of their study of 509 patients with moderately to severely active Crohn's disease and elevated C-reactive protein levels.</div> <div> They were randomized to receive natalizumab 300 mg or placebo intravenously at the start of the study and 4 and 8 weeks later.</div> <div> In all, 48% of natalizumab patients and 32% of placebo patients showed a decrease of 70 points or more in the Crohn's Disease Activity Index (CDAI) score at 8 through 12 weeks (p < 0.001). Active treatment patients also showed higher response rates at 4 and 8 weeks.</div> <div> Sustained remission, defined as a CDAI score less than 150 points, was seen in 26% of natalizumab patients and 16% of placebo patients (p = 0.002), the investigators report.</div> <div> Adverse event frequencies were similar in both groups, and in fact, "patients receiving placebo experienced more serious adverse events than those treated with natalizumab," the team found.</div> <div> They note in their discussion of the results that elevated CRP identifies patients whose symptoms are likely driven by inflammation. Patients with other causes such as bile salt diarrhea or bacterial overgrowth are unlikely to benefit from agents targeting inflammatory pathways.</div> <div> Nonetheless, the researchers advise that CRP "should not be the sole or the most important factor upon which treatment decisions are made." Factors such as endoscopic findings, the ESR, and response to prior treatments "should all be considered when attempting to determine appropriate patient treatment."</div> <div> Summing up, Dr. Targan and colleagues conclude that taken together with data from previous induction trials, the findings "indicate that natalizumab is effective for induction of sustained response and remission in patients with Crohn's disease and active inflammation as evidenced by elevated CRP concentration and may represent an alternative treatment option ... in appropriately selected patients."</div> <div> <I>Gastroenterology.</I> 2007;132:1672-1683.</div> <div> Reuters Health Information 2007. © 2007 Reuters Ltd.</div> <div> <B>Learning Objectives for This Educational Activity</B></div> <div> Upon completion of this activity, participants will be able to: </div> <div> Describe the efficacy of natalizumab in inducing response and remission in patients with moderately to severely active Crohn's disease. </div> <div> Describe the tolerability of natalizumab used in this setting. </div> <div> <B>Clinical Context</B></div> <div> The mechanism of Crohn's disease involves recruitment of leukocytes into gut tissue and dysregulated activation of immune cell function, mediated via the a4 integrins. Natalizumab is a humanized immunoglobulin G4 monoclonal antibody against a4 integrins. In previous studies, natalizumab was effective as induction therapy for patients with moderately to severely active Crohn's disease.</div> <div> Although the Efficacy of Natalizumab as Active Crohn's Therapy (ENACT-1) trial did not meet the primary endpoint of response at week 10, the Evaluation of Natalizumab as Continuous Therapy (ENACT-2) trial clearly showed the efficacy of natalizumab as a maintenance therapy in patients who responded to induction therapy. This report describes the Efficacy of Natalizumab in Crohn's Disease Response and Remission (ENCORE) trial, which was designed to confirm that natalizumab is effective as an induction therapy in patients with moderately to severely active Crohn's disease and active inflammation characterized by elevated C-reactive protein concentrations.</div> <div> <B>Study Highlights</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">ENCORE was done at 114 centers between March 2004 and March 2005. Inclusion criteria were moderately to severely active Crohn's disease confirmed by radiologic or endoscopic studies within previous 36 months or following prior surgical resection, C-reactive protein concentration greater than 2.87 mg/L, 18 years of age or older, Crohn's disease Activity Index (CDAI) scores of 220 to no more than 450, and Crohn's disease duration of 6 months or longer. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Concurrent Crohn's disease therapies were allowed. Exclusion criteria were short-bowel syndrome, ostomy, total colectomy, stricture with obstructive symptoms, draining fistulas, abdominal abscess, anti–tumor necrosis factor therapy within previous 12 weeks, or previous natalizumab treatment. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Of 832 patients screened, 509 were eligible and randomized 1:1 to receive natalizumab (300 mg) or placebo intravenously at weeks 0, 4, and 8; they were followed up until week 12 for safety and efficacy assessments. Baseline characteristics were similar in both groups. Patients, site staff, and investigators were all blinded to treatment assignment. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Main outcome was induction of response (> 70-point decrease from baseline in CDAI score at week 8 sustained through week 12). Other outcomes were proportion of patients with sustained remission (CDAI < 150 points) and response or remission over time. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Response at week 8 sustained through week 12 occurred in 48% of natalizumab group vs 32% of placebo group (<I>P</I> < .001), and sustained remission occurred in 26% vs 16%, respectively (<I>P</I> = .002). At week 4, response rates were 51% for natalizumab and 37% for placebo (<I>P</I> = .001), and responses remained higher at later assessments in natalizumab group (<I>P</I> < .001). Remission rates at weeks 4, 8, and 12 were also higher with natalizumab vs placebo (<I>P</I> < .009). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Both groups had similar frequency and types of adverse events, which were recorded at each visit. Safety assessments included vital signs, physical examinations, hematology, serum biochemistry, urinalysis, and testing for antinatalizumab antibodies (positive, = 0.5 µg/mL in validated enzyme-linked immunosorbent assay at any time point). Natalizumab was well tolerated. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Overall, 39 patients (15%) receiving natalizumab and 42 patients (17%) receiving placebo withdrew prematurely from study. Treatment was discontinued because of an adverse event in 9% vs 13%, respectively. Most common adverse events (reported by = 10% of patients in both groups) were headache, nausea, abdominal pain, nasopharyngitis, dizziness, fatigue, and Crohn's disease exacerbation. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Serious adverse events occurred in 5% of the natalizumab group vs 10% of the placebo group. The most common serious adverse event, Crohn's disease exacerbation, occurred in 3% vs 6%, respectively. There was 1 case of basal cell carcinoma in a patient receiving natalizumab. Infections occurred in 35% of the natalizumab group vs 30% of the placebo group, primarily because of more frequent nasopharyngitis in the natalizumab group (11% vs 6%). Serious infections occurred in 1 patient in the natalizumab group (perianal abscess not considered related to study drug) and in 4 in the placebo group. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acute infusion reactions occurred in 9% of the natalizumab group vs 7% of the placebo group. Hypersensitivity-like reactions occurred in 4% of the natalizumab group vs less than 1% of the placebo group; all were medically nonserious and responded quickly to appropriate medical therapy. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">During weeks 0 to 12, 9.5% of the natalizumab group tested positive for antinatalizumab antibodies on at least 1 occasion; 22% of these had acute infusion reactions vs 8% of those who tested negative. Incidence of hypersensitivity-like reactions was 17% vs 3%, respectively. </div> <div> <B>Pearls for Practice</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In patients with moderately to severely active Crohn's disease, natalizumab induced response and remission at week 8 that was sustained through week 12. Response and remission rates for natalizumab were superior to those for placebo at weeks 4, 8, and 12. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Natalizumab was well tolerated in this study, with frequency and types of adverse events in the natalizumab group being similar to those in the placebo group. </div> <div> <B>Instructions for Participation and Credit</B></div> <div> There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.</div> <bR> <div> This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page.</div> <bR> <div> FOLLOW THESE STEPS TO EARN CME/CE CREDIT*: </div> <div> Read the target audience, learning objectives, and author disclosures. </div> <div> Study the educational content online or printed out. </div> <div> Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. Medscape encourages you to complete the Activity Evaluation to provide feedback for future programming. </div> <div> You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 5 years; at any point within this time period you can print out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage.</div> <bR> <div> *The credit that you receive is based on your user profile.  <A NAME="target"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <B>Target Audience</B></div> <div> This article is intended for primary care clinicians, gastroenterologists, and other specialists who care for patients with Crohn's disease.</div> <div> <B>Goal</B></div> <div> The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.</div> <bR> </td> </tr></table></body>