A Note on Peptic Ulcers
Department of Pharmaceutical Technology, Andhra University, Visakhapatnam
- *Corresponding Author:
- Joshita Sabbineni
Department of Pharmaceutical Technology
Andhra University, Visakhapatnam
E-mail: [email protected]
Received date: 04/10/2016; Accepted date: 05/10/2016; Published date: 11/10/2016
Visit for more related articles at Research & Reviews: Journal of Pharmacognosy and Phytochemistry
Peptic ulcer is the disease that develops in the form of sores in the lining of the stomach, oesophagus or small intestine. The most common symptom of this disease is abdominal pain that occurs from stomach region to the chest part. If the ulcer is left untreated then it may result in other adverse health conditions. The peptic ulcers usually occur as a result of imbalance of acid secretion and mucosal defences that resist the acid digestion. Accounting to the developments in the medical treatment of peptic ulcer disease (PUD) in the last two decades, surgical intervention is currently confined to the treatment of complicated disease, namely, ulcer hemorrhage, perforation, penetration and obstruction. Generally the major cause of the disease is H.pylori infection. The eradication of the infection completely helps to decrease the incidence of the disease.
H.pylori; Peptic ulcer; Gastric mucosa
Helicobacter pylori ordinarily colonizes the gastric mucosa of more than half of the humans around the world, bringing on a disease that may show up in early adolescence and can hold on forever [1-5]. Surgical intervention is currently limited to the treatment of ulcer hemorrhage, perforation, penetration and obstruction [6-18]. Generally the major cause of the disease is H.pylori infection. H. pylori are proposed as the primary reason of peptic ulcer and incessant gastritis. It is likewise connected with gastric disease [19,20]. It’s seriousness and side effects rely upon ecological variables, host powerlessness and bacterial parts, which permit H. pylori to switch amongst commensalism and pathogenicity [21-25]. H. pylori are hereditarily very variable, and the variability which influences H. pylori virulence may be helpful in distinguishing the strains with various degrees of pathogenicity. The geographic distribution of distinct [26-30]. H. pylori genotypes are generally obscure and ought to be set up. The predominance of more pathogenic genotypes in specific ranges may have essential epidemiological outcomes. It additionally may be connected with the seriousness of H. pylori related ailments in such areas [31-33]. Helicobacter pylori colonization induces lively natural and particular insusceptible reactions; be that as it may, the contamination does not vanish and a ceaseless gastritis condition persists if left untreated [34-40]. It has been demonstrated that the geological factors and insusceptible reaction of gastritis are the primary purposes behind the bacteria persistence and the clinical outcome. Gastritis occurring due to H. pylori is due to connection among an assortment of T cell subsets.
The discovery of Helicobacter pylori as the reason in peptic ulcer disease (PUD) has revolutionized its management. Despite the availability of effective drug treatments and a better understanding of its disease condition and symptoms, the percentage of patients who require emergent surgery for complicated disease remains constant at 7% of hospitalized patients [41-50]. Peptic ulcers are the sores formed in the lining of stomach or duodenum. The ulcer formation usually occurs due to the reaction between the bacteria in the stomach and non-steroidal anti-inflammatory medications in 50 % of affected population [51-55]. For the other half of the population it occurs due to drugs, severe stress, genetic factors, smoking, drinking etc. Peptic ulcer is a common disease that affects millions of people worldwide. Considering its global prevalence finding new approach for treating is important [55-60].
The main symptoms of the disease are:
• Burning pain in the upper abdominal wall lining [61,62]
• Acid reflux or heart burn
• Feeling of satiatment while eating
• Weight loss
• Bloating or burping
• Nausea and vomiting [63-66]
Generally when the ulcerative condition is left untreated then it may result in further complications like:
Bleeding can occur as slow blood loss that leads to anemia or as severe blood loss that may require hospitalization or a blood transfusion. Severe blood loss may cause black or bloody vomit or black or bloody stools [67,68].
Peptic ulcers can eat a hole through (perforate) the wall of your stomach or small intestine, putting you at risk of serious infection of your abdominal cavity (peritonitis) .
Peptic ulcers can lead to swelling, inflammation or scarring that may block passage of food through the digestive tract. A blockage may make you become full easily, vomit and lose weight .
Diagnosis of Peptic Ulcer
The diagnosis of the peptic ulcer depends on the symptoms and severity of the ulcer condition. The diagnosis of the disease includes the following methods:
This test is done to rule out the presence of bacterial H.pylori infection and this is done by taking stool sample test, blood test which helps the doctor to detect the presence of infection [71-75].
This test gives most accurate results compared to blood tests. In this test the patient is asked to consume food containing radioactive carbon. H.pylori breaks down the substance in the stomach [76-79]. Later the patient is asked to blow into a bag which is sealed and if the patient is infected with the bacterial infection then the breath sample will contain radioactive carbon in the form of carbon dioxide.
In this test the doctor examines the upper digestive system by passing a hollow tube fitted with lens (endoscope) down the throat into oesophagus, stomach and small intestine to check out for ulcers. If ulcers are detected then a sample of tissue is taken for examination [80-84]. If the endoscopy shows an ulcer in your stomach, a follow-up endoscopy should be performed after treatment to show that it has healed, even if your symptoms improve [85,86].
This test is also referred to as upper gastrointestinal series. In this test the patient is asked to swallow a while liquid containing barium which helps in coating the intestinal wall and makes the ulcers more visible.
The treatment for the disease is dependent on the cause of the ulcer. Generally majority of the ulcerative conditions are treated with in the initial stages but sometimes surgery may be required [87-90]. The treatment is usually classified into two type i.e.
This sort of treatment is preferred in case of the ulcers caused by the H.pylori. Generally antibiotics are used to treat this condition. The drug regimen usually includes:
• H2 blockers which are used to decrease the acid production in the stomach
• Proton pump inhibitors that block the cells that produce gastric acid
• Antacids which act by neutralising stomach acid [91-93]
• Cytoprotective agents which are used to protect the lining of the stomach and small intestine.
In some rare cases such as recurrence of ulcers, internal bleeding, ulcers which tear the stomach lining only surgery may be suggested. The surgery may include complete removal of ulcer, grafting a tissue from other body part and sewing it over the affected area, tying off a bleeding artery, cutting off the nerve supply to stomach to reduce the production of stomach acid [94-96].
Prevention of Peptic Ulcers
There is a plenty of writing concerning gastritis and peptic ulcer sickness brought on by the bacterium Helicobacter pylori. By the by, there is still much to be found out about this bacterium and its impacts on the human body. It may not be known precisely how H. pylori are transmitted yet at any rate we can recognize and destroy the bacterium without lifting a finger and productivity. Numerous better approaches to counteract and repress the action of H. pylori are being found. Presently it is up to the researchers to find far and away superior approaches to treat the illness brought on by this bacterium and to discover approaches to keep the sickness. Whenever H. pylori's method of transmission is at last found, it might prompt more proficient approaches to avert transmission and disease .
Most peptic ulcers are promptly treatable by a short course of restorative medications. The possibility of preventing the foundation of H.pylori by immunization stays to develop an implemented. The role of NSAIDs in peptic ulceration is clearly defined but is still not widly recognised .
Like structural designing for waterways, the medicinal administration of ulcer ought not to be founded on a straightforward cause-impact relationship. Treatment should be acclimated to individual patients and should be outlined by taking the association of numerous causative variables (counting H. pylori furthermore, push) into thought. At the end of the day, the bio-psycho-social methodology is vital for the treatment of peptic ulcer [99,100].
To avert peptic ulcers, stay away from the accompanying:
• Normal wellsprings of Helicobacter pylori microscopic organisms (e.g., debased sustenance and water, floodwater, crude sewage)
• Long haul utilization of non-steroidal calming drugs (NSAIDs)
Great cleanliness can decrease the danger for peptic ulcer malady created by Helicobacter pylori disease. Washing the hands completely with warm sudsy water subsequent to utilizing the restroom and before eating and abstaining from sharing eating utensils and drinking glasses likewise can diminish the spread of microbes that can bring about PUD.
Although there are significant advances in sciences, this disease remains an important medical problem, because the large use of non-steroidal anti-inflammatory drugs (NSAIDs), excessive smoking, increase alcohol consumption, and life style increase the risk of the disease. Therefore, this explains the reason for choosing this topic in order to promote healthy behavior and improve health outcomes throughout lifespan by giving attention to the preventive measures.
- Subudhi BB, Sahoo SP, Sahu PK. Updates in Drug Development Strategies against Peptic ulcer. J Gastrointest Dig Syst2016; 6:398.
- Olsen PS et al. Role of submandibular saliva and epidermal growth factor ingastric cytoprotection. Gastroenterology 1984;87:103-108.
- Mureşan S, et al. Non Peptic Ulcer Upper Gastrointestinal Bleeding in Patients Treated with Non-Steroidal Anti-inflammatory Drugs for Musculo-Articular Disorders. Journal of Surgery 2015;11:113-116.
- Zaghlool SS, et al. Comparison between the Protective Effects of Famotidine, Ginger and Marshmallow on Pyloric Ligation-Induced Peptic Ulcer in Rats. J BioequivAvailab2015;7:170-178.
- Davenport HW. Fluid produced by the gastric mucosa during damage by acetic and salicyclicacids.Gastroenterology 1966; 50: 487.
- Rainsford KD. Prostaglandins and the development of gastric mucosal damage by anti-inflammatorydrugs. In : Prostaglandins and Inflammation, by Rainsford KD and Hutchinson AW, Birkhauser,Basel: 1.
- Bennett JR. Smoking and the gastrointestinal tract.Gut 1972;13:658-665.
- Ju H, et al. Diagnostics for Statistical Variable Selection Methods for Prediction of Peptic Ulcer Disease in Helicobacter pylori Infection. J Proteomics Bioinform2014 ;7:095-101.
- AyantundeAA . Current Opinions in Bleeding Peptic Ulcer Disease. J Gastroint Dig Syst2014; 4:172.
- Elgamrani Y, et al. Rare Association: Celiac Disease and Ulcerative Colitis. J Med DiagnMeth 2016; 5:223.
- Abd-Elmenm SM, et al. Evaluation of the Role of Adipose-Derived Stem Cells in the Healing of Indomethacin-Induced Gastric Ulceration in Rats. J Cell SciTher2016; 7: 246.
- Rosenblum J andPapamichael M.Combined Ultrasound and Electric Field Stimulation Aids the Healing of Chronic Pressure Ulcers. J GerontolGeriatr Res 2016;5:319.
- Kgomo MK, et al. The Prevalence of Helicobacter Pylori Infection in Bleeding and Non Bleeding Gastric Ulcers. A Cross Sectional Case Control Study. J Bioanal Biomed 2016;8:058-062 .
- Vilela LHR, et al. Pain Assessment in Patients with Venous Leg Ulcer Treated by Compression Therapy with Unna’s Boot. J Tissue SciEng2016;7:171.
- Sreelakshmy V, et al. Green Synthesis of Silver Nanoparticles from Glycyrrhizaglabra Root Extract for the Treatment of Gastric Ulcer. J Develop Drugs 2016;5:152.
- Connelly TM, et al. Genetic and Demographic Correlates of Quality of Life after Ileal Pouch Anal Anastomosis for Ulcerative Colitis. J Inflam Bowel Dis &Disord2016;1:107.
- Yan Xia S, et al. A New Approach to Reduce Pressure Ulcers and Improve Health of Scoliosis Surgery Patients. J Nurs Care 2016;5:343.
- Sasaki K.Duodenal Gastrinoma Associated with Multiple Endocrine Neoplasia Type 1 MEN1 Detected by Esophagogastroduodenoscopy EGD, which was buried under Ulcer . J Gastrointest Dig Syst2016;6:418.
- Wyatt JI,et al. Campylobacter pyloridis and acid induced gastricmetaplasia in the pathogenesis of duodenitis. J ClinPathol 1987; 40: 841-848.
- Marques RR and Farina Jr. Treatment and Management. J Community Med Health 2016;6:402.
- Yang L,et al. Associations between Markers of Colorectal Cancer Stem Cells, Mutations, Mirna, and Clinical Characteristics of Ulcerative Colitis. Transl Med Sunnyvale 2016;6:168.
- Aldeguer. Letters to the Editor: Cost of Ulcerative Colitis. J Colitis Diverticulitis 2016;1:1000102.
- Manfredi M, et al. Cutaneous Leishmaniasis with Long Duration and Bleeding Ulcer. ClinMicrobiol2016;5:229.
- Mary SJ andMerina AJ.Gastroprotective Effect of Guttardaspeciosa against Ethanol Induced Gastric Ulcer in Rats. Med Aromat Plants 2015;5:224.
- Love BL, et al. Adherence to 5-Aminosalicylic Acid Treatment in Ulcerative Colitis . J HepatolGastroint Dis 2015;1:107.
- Chowdhury ATMM, et al. Deep Gastric Ulcer with Formation of Fistula along the Stomach Wall. J HepatolGastroint Dis 2015;1:i102.
- Chowdhury ATMM, et al. An Unusual Presentation of Ulcerative Colitis with Numerous Colon Polyps and Formation of Multiple Band and Septum Like Structures in the Colonic Lumen. J HepatolGastroint Dis 2015;1:i101.
- Fonseca C, et al. Nursing Interventions in Prevention and Healing of Leg Ulcers:Systematic Review of the Literature. J Palliat Care Med 2015;5:238.
- Ismail AE, et al. Role of Autologous Bone Marrow Stem Cell Transplantation in the Treatment of Active Ulcerative Colitis. J Stem Cell Res Ther 2015;5:313.
- Sundlass NK, et al. Infliximab- Induced Linear Iga Bullous Disease in a Patient with Ulcerative Colitis. J Clin Case Rep 2015;5:597.
- El Moussaoui N, et al. Multiple Skin Ulcerations Revealing a ParaneoplasicDermatomyositis. J Clin Trials 2015;5:239.
- Shivakumar Singh P,et al. Documentation of Folkloric Knowledge on Medicinal Plants Used in the Treatment of Mouth Ulcers in KodangalMandal, Mahabubnagar District, Telangana, India. J Bioanal Biomed 2015;7:174-179.
- Banala N, et al. Design and Evaluation of Floating Multi Unit Mini Tablets MUMTS Muco Adhesive Drug Delivery System of Famotidine to Treat Upper Gastro Intestinal Ulcers. J Pharmacovigil2015;3:179.
- Rainsford KD andBrune K. Role of the parietal cell in gastric damage induced by aspirin and related drug implications for same therapy. Med J Aust 1976; 1: 881-883.
- Goldring M, et al. The Help Seeking Behaviours of Patients with Ulcerative Skin Lesions before Consultation in Yurimaguas, Peru. J Anc Dis Prev Rem 2015;3:127.
- Sandle TIncidences and Treatments for Buruli Ulcer. J Anc Dis Prev Rem 2015;3:e122.
- Domínguez Á andVelásquezSA . Topical Gel Application and Low Level Laser Therapy on Related Soft Tissue Traumatic Aphthous Ulcers: A Randomized Clinical Trial. J Laser Opt Photonics 2015;2:119.
- Frimpong M, et al. Microscopy for Acid Fast Bacilli: A Useful but Neglected Tool in Routine Laboratory Diagnosis of Buruli Ulcer. J Trop Dis 2015;3:158.
- Hazmi AA, et al. Synchronous Perforation of Transverse and Sigmoid Colon due to Ulcerative Colitis: A Rare Case Report. Journal of Surgery2015;11: 349-350.
- Kumar A, et al. The Foot Care Process of Diabetic Patients With and Without Foot Ulcer Attending A Tertiary Care Hospital in India. J Stem Cell Res Ther 2015;5:280.
- MaciochT,et al. The Indirect Costs of Diabetic Foot Ulcers in Poland. J Diabetes Metab2015;6:540.
- SanchesKP,et al. Case Report: Moderately Differentiated Ulcerated Gallbladder Squamous Cell Carcinoma. Surgery Curr Res 2015;5:230.
- Mani P,et al. Treatment and Replenishment of G.I. Tract with Combined Regimen Therapy CRT of Allopathic PPIs and Ayurvedic Aloe Vera Medicine in Peptic Ulcer Disease to Counteract Relapse. J Gastrointest Dig Syst2015;5:272.
- Kadhim G, et al. Risk Factors Associated with Peptic Ulcer Disease. J Bioengineer & Biomedical Sci2015;5:142.
- Kryczka T andGrieb P. Supportive Treatment of Pressure Ulcers with Dietary Supplementation. ClinPharmacolBiopharm2015;3:130.
- Evers F, et al. Periodontitis, an Often-Overlooked Reservoir for Bacteria, in a Patient with Decubital Ulcer. ClinMicrobiol2015;4:189.
- Dan D,et al. Free Perforation of Ileal Tubercular Ulcer- A Case Report and Literature Review. ClinMicrobiol2015;4:182.
- Zweifel DF, et al. Unusual Cause of Gingival Ulcer. Oral Hyg Health 2014;2:158.
- GhoshGC,et al. Non Alcoholic Wernicke’s Encephalopathy with Cortical Involvement in a Patient of Active Peptic Ulcer Disease. J Clin Case Rep 2014;4:379.
- Erdogan EI .Gastric Ulcer in a Patient with Percutaneous Endoscopic Gastrostomy. J Gastroint Dig Syst2014;4:213.
- Alkofahi A, and Atta AH. Pharmacological screening of the anti-ulcerogenic effects of some Jordanian medicinal plants in rats. J Ethnopharmacol1999;67:341-345.
- William M and Pounder RE .An audit of proton pump inhibitor usage in a teaching hospital setting. Gut 1997;40: A59.
- vanVliet EP, et al. Inappropriate prescription of proton pump inhibitors on two pulmonary medicine wards. Eur J GastroenterolHepatol2008;20:608-612.
- ShafiS,et al. Proton pump inhibitors-over-prescribed in a rural community? Pak J Med Sci2011;27:300-302.
- Jai Moo Shin andNayoung Kim.Pharmacokinetics and Pharmacodynamics of the Proton pump inhibitors. J NeurogastroenterolMotil2013;19: 25-35.
- Fock KM, et al. Proton pump inhibitors: do differences in pharmacokinetics translate into differences in clinical outcomes? ClinPharmacokinet2008;47: 1- 6.
- Hung OY, et al. Hypergastrinemia, Type 1 Gastric Carcinoid Tumors; Diagnosis and Management, J ClinOncol2011;25:e713-5.
- ZelicksonMS,et al. Helicobacter pylori is not the predominant etiology for peptic ulcers requiring operation. Am Surg201177: 1054-1060.
- Bertleff MJ and Lange JF. Perforated peptic ulcer disease: areview of history and treatment. Dig Surg2010 ;27: 161-169.
- Lau JY, et al. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 2011;84: 102-113.
- Svanes CTrends in perforated peptic ulcer: incidence, etiology, treatment, and prognosis. World J Surg2000;24: 277-283.
- Møller MH, et al. Perforated peptic ulcer: how to improve outcome?.Scand J Gastroenterol2009;44: 15-22.
- Thorsen K, et al. Trends in diagnosis and surgical management of patients with perforated peptic ulcer. J GastrointestSurg2011;15: 1329-1335.
- Gisbert JP, et al. Helicobacter pylori and perforated peptic ulcer prevalence of the infection and role of non-steroidal anti-inflammatory drugs. Dig Liver Dis 2004;36: 116-120.
- Kurata JH andNogawa AN.Meta-analysis of risk factors for peptic ulcer. Nonsteroidalantiinflammatory drugs, Helicobacter pylori, and smoking. J ClinGastroenterol1997;24: 2-17.
- Manfredini R, et al. Seasonal pattern of peptic ulcer hospitalizations: analysis of the hospital discharge data of the Emilia-Romagna region of Italy. BMC Gastroenterol2010;10: 37.
- Janik J and Chwirot P. Perforated peptic ulcer–time trends and patterns over 20 years. Med SciMonit2000;6: 369-372.
- Svanes C, et al. Rhythmic patterns in incidence of peptic ulcer perforation over 5.5 decades in Norway. ChronobiolInt1998;15: 241-264.
- Watts DD andFakhry SM.Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the East multi-institutional trial. J Trauma 2003;54: 289-294.
- Oosting SF, et al. patient with metastatic melanoma presenting with gastrointestinal perforation after dacarbazine infusion: a case report. J Med Case Reports 2010;4: 10.
- Golffier C, et al. A Duodenal perforation because of swallowed ballpoint pen and its laparoscopic management:report of a case. J PediatrSurg2009;44: 634-636.
- Goh BK, et al. Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg2006;30 : 372-377.
- Jalihal A and Chong VHDuodenal perforations and haematoma: complications of endoscopic therapy. ANZ J Surg2009;79: 767-768.
- Bianchini AU, et al. Duodenal perforation by a Greenfield filter: endoscopic diagnosis. Am J Gastroenterol1997;92: 686-687.
- Feezor RJ, et al. Duodenal perforation with an inferior vena cava filter: an unusual cause of abdominal pain. J VascSurg2002;35: 1010-1012.
- Mao Z, et al. Duodenal perforations after endoscopic retrograde cholangiopancreatography: experience and management. J LaparoendoscAdvSurg Tech A 2008;18: 691-695.
- Palanivelu C, et al. Laparoscopic management of a retroperitoneal duodenal perforation following ERCP for periampullary cancer. JSLS 2008;12: 399-402.
- Zeb F, et al. Duodenal impaction/perforation of a biliary stent – a rare complication in the management of choledocholithiasis. J Gastrointestin Liver Dis 2009;18: 391-392.
- FY Le, et al. Predicting mortality and morbidity of patients operated on for perforated peptic ulcers. Arch Surg2001;136: 90-94.
- Arici C, et al. Analysis of risk factors predicting affecting mortality and morbidity of peptic ulcer perforations. IntSurg2001;92: 147-154.
- Kocer B, et al. Factors affecting mortality and morbidity in patients with peptic ulcer perforation. J GastroenterolHepatol2001;22: 565-570.
- Bucher P,et al. Results of conservative treatment for perforated gastroduodenal ulcer in patients not eligible for surgical repair. Swiss Med Wkly2007;137: 337-340.
- Boey J, et al. Risk stratification in perforated duodenal ulcers. A prospective validation of predictive factors. Ann Surg2001;205: 22-26.
- Siu W, Leong H, Law B, Chau CH, Li AC, et al. 2002Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg235: 313-319.
- Uccheddu A, et al. Surgery for perforated peptic ulcer in the elderly. Evaluation of factors influencing prognosis. Hepatogastroenterology2003;50: 1956-1958.
- Tsugawa K, et al. The therapeutic strategies in performing emergency surgery for gastroduodenal ulcer perforation in 130 patients over 70 years of age. Hepatogastroenterology2001;48: 156-162.
- Linder MM, et al. The Mannheim Peritonitis Index. An instrument for the intraoperative prognosis of peritonitis. Chirurg2010;58: 84-92.
- Moller MH, et al. The Peptic Ulcer perforation (PULP) score: a predictor of mortality following peptic ulcer perforation. A cohort study. ActaAnaesthesiolScand2012;56: 655-662.
- So JB, et al. Risk factors related to operativemortality and morbidity in patients undergoing emergencygastrectomy. Br J Surg2000;87: 1702-1707.
- LuneviciusR andMorkevicius M .Systematic review comparing laparoscopic and open repair for perforated peptic ulcer. Br J Surg 2005; 92: 1195-1207.
- SC L e, et al. (2002) Candida peritonitis due to peptic ulcer perforation: incidence rate, risk factors, pronosis and susceptibility to fluconazole and amphotericin B. Diagn Micro Infect Dis 2002; 44: 23-27.
- Boey J, et al. (1982) Bacteria and septic complications in patients with perforated duodenal ulcers. Am J Surg1982;143: 635-639.
- Thorsen K, et al. What is the best predictor of mortality in perforated peptic ulcer disease? A population-based, multivariable regression analysis including three clinical scoring. Systems J GastrointestSurg 2014;5:31-35.
- Nomani AZ, et al. A new prognostic scoring system for perforation peritonitis secondary to duodenal ulcers. J Pak Med Assoc 2014;64: 50-56.
- Koo J and SK N Trends in hospital admissions, perforation and mortality of perforation and mortality of peptic ulcer in Hng Kong from 1970–1980. Gastroenterology 1983;84: 1558-1562.
- Malhotra AK, et al. Blunt bowel and mesenteric injuries: the role of screening computed tomography. J Trauma 2000;48: 991-1000.
- Fakhry S, et al. The EAST Multi-institutional HVI Research Group: Diagnosing blunt small bowel injury (SBI): an analysis of the clinical utility of computerized tomography (CT) scan from a large multi-institutional trial. J Trauma 2001;51: 1232.
- Jacobs DG, et al. Peritoneal lavage white count: a reassessment. J Trauma 1990;30: 607.
- RozyckiGS,et al. Surgeon-performed ultrasound for the assessment of truncal injuries. Ann Surg 1998;228: 557.
- Crofts TJ, et al. A randomized trial of nonoperative treatment for perforated peptic ulcer. N Engl J Med 1989;320: 970-973