as type IIIgastric ulcers (@ 20%), and because of their common association with gastric acid hypersection, they are assumed to be similar in origin to duodenal ulcers. Csendes et al.l ' recognized a fourth variety of gastric ulcer, which they call type IV. This ulcer occurs high on the lesser curvature near the gastroesophageal junction. It accounts for 25% of gastric ulcers in Chile, where it was first described, and is being
seen with increasing frequency in the United States. Because histologic studies have shown that proximal migration of the gastric nonparietal mucosa can occur along the lesser curvature to the level of the gastroesophageal junction, "type IV ulcers" likely represent very high type I ulcers. Although the Johnson classification has proved useful in helping to understand responses to treatment when other risk factors are excluded, patients who develop gastric ulceration secondary to NSAID use do not conform to this classification. NSAID ulcers typically occur in the antrum but may be located anywhere in the stomach and may be multiple in origin, in contrast to the single ulceration usually seen in gastric ulcer disease. Some
Figure 6-1 Gastric ulcer classification (From Matthews, J.B., and Silen, W.: Operations for peptic ulcer disease and their complications. In Sleisenger, M.H., and Fordtran, J.S. (eds.): Gastrointestinal Disease, 5th ed. Philadelphia, W.B. Saunders, 1993.)
TABLE 6-2 -- Approved Triple-Therapy Regimens
BMT (14 days of treatment)
Bismuth subsalicylate (2 tablets four times daily) Metronidazole (250 mg four times daily) Tetracycline HCl (500 mg four times daily)
An H2 -receptor antagonist is added to the regimen for the 14 days of treatment and for an additional 4 weeks.
LAC (approved for 10 or 14 days of treatment)
Lansoprazole (30 mg two times daily) Amoxicillin (1 g two times daily) Clarithromycin (500 mg two times daily)
Omeprazole (20 mg two times daily) Amoxicillin (1 g two times daily) Clarithromycin (500 mg two times daily)
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