Invited Commentary

Abstract

Invited CommentarySeveral recent reports suggest a relationship between infections caused by Helicobacter species and gastrointestinal tract disease. As noted by Dr Kozol, there is good evidence that antibiotic treatment directed at the eradication of Helicobacter infection, in conjunction with suppression of gastric acid secretion, is an effective way of dealing with duodenal and gastric ulcers. Furthermore, a National Institutes of Health (Bethesda, Md) Consensus Statement1 concluded that although all infected patients with ulcers should be treated, even those with a history of concomitant use of nonsteroidal anti-inflammatory agents, there was insufficient evidence to justify the treatment of infected individuals who do not have demonstrable mucosal lesions.Confronted by the barrage of information surrounding Helicobacter species and their putative role in the causality of ulcers, it is appropriate that the role of surgical interventions for ulcer be reevaluated. When this important topic was con¬ sidered prior to the current information about Helicobacter species (pre-H pylori era), the issues that required consideration would have been the chronicity of the ulcer process; the presence of anatomic deformities, such as severe pyloric stenosis, prepyloric or antral ulcers in conjunction with duodenal deformity, or extremely large size (giant gastric or duodenal ul¬ cers); or other associated comorbidities that affect the natural history of ulcer disease. All of these factors are related to risks of ulcer recurrence. Previously, therefore, patients with refractory or recurrent symptoms following treatment were candi¬ dates for one of several candidate operative treatments. Furthermore, ulcer operations have been effective in treating all of the complications of ulcers, without reference to the presence of H pylori infection.2,3Now, in the post-H pylori era, we are seeing patients with bleeding or partial gastric outlet following treatment with anti-H pylori antibiotics in addition to antisecretory medications. Based on this uncontrolled series of patients, I suspect that there will be many more who require operative treatments for the usual reasons. If anti-H pylori treatment is found tobe less than ideal in preventing ulcer recurrence, the total number of once-thought-ideal medical remedies for ulcer will be in¬ creased by one; this would not be surprising in light of previous experience with ulcer remedies. Surgeons will continue to have a role in the treatment of duodenal ulcer.The pathogenesis and perpetuation of hepatocellular injury in hepatitis C viral infection remains unclear. It has been pro¬ posed that a direct viropathic effect, the host immune response, or both mediate cell damage. To address this issue, the immunophenotype of the inflammatory infiltrate in the liver of 18 patients with abnormal liver function tests and serologically detectable hepatitis C virus antibodies was compared with seven control patients (three cases with hepatitis B virus infec¬ tion, two with alcoholic hepatitis, and one ...