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Saturday, 26 October 2013

Duodenitis

Duodenitis is defined as a condition of inflammation in the lining of the duodenum, the first section of the small intestine.

I. Symptoms
1. Abdominal pain
In a report of Thirty nine children with recurrent abdominal pain aged between 5.5 and 12 years, underwent endoscopic duodenal biopsy. Duodenal inflammation was graded by the duodenitis scale of Whitehead et al (grade 0, 1, 2, and 3). In 13 out of 39 patients (33%) definite signs of inflammation were found (grade 2 and 3). Intestinal permeability to 51Cr-EDTA in patients with duodenitis (grade 1, 2, and 3) was significantly higher (4.42 (1.73)%) than in patients with normal (grade 0) duodenal biopsy appearances (3.3 (0.9)%)(1).

2. Loss of appetite, epigastric pain and weight loss
Parasitic infection cause of  Duodenitis can lead to loss of appetite and weight loss, according to the study of An extremely uncommon case of parasitic infection presenting as eosinophilic ascites in a young patient, by thye research team at the GATA Haydarpasa Training Hospital(2).

3. Other symptoms
In the study of over a 15 month period, 124 referred patients were evaluated in a prospective cohort analysis with a standardised investigation including duodenal biopsies and aspirate, blood tests and faecal parasite and calprotectin tests. Recovered subjects were recruited for symptom analysis, researchers at the Haukeland University Hospital, found that There were significant associations between persistent Giardia positivity, microscopic duodenal inflammation and a positive calprotectin test. In patients with persisting symptoms after metronidazole treated Giardia infection we commonly found chronic Giardia infection and microscopic duodenal inflammation, especially in illness duration less than 7 months. Both these findings subsided over time. Increasingly, investigations could not determine a definite cause for the persistent symptoms. The very long-term post-giardiasis diarrhoea, bloating, nausea and abdominal pain documented here need further study(3). 

4. Etc.

II. Causes and Risk factors 
A. Causes
1. Medication
Prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin), naproxen (Aleve), or aspirin, in some people, it can lead to irritation causes of  inflammation in the lining of the duodenum. There is a report of a 40-year-old previously healthy white man presented to the emergency department at American University of Beirut Medical Center, Beirut, Lebanon, with developed symptomatic severe transmural duodenitis and periduodenal mesenteric streaking, consistent with a complicated ulcer, probably associated with very short-term exposure to tiaprofenic acid(3a).

2. Bacteria infections (Helicobacter pylor)
In the study of 138 (92 males, 46 females) patients aged 4.5-85 years [mean (7) = 45+/-SD 17.8 years] who had upper gastrointestinal endoscopy were analyzed for presence of H. pylori, found that eighty-three had histopathology alone, while 55 others had both histology and culture. Endoscopic diagnosis included duodenal ulcer (DU) (n=35, 23%); gastric ulcer (n=4, 3%); gastric cancer (n=14, 9%); NUD, including gastritis (n=49, 32%); duodenitis (n=47, 31%); and normal (n=16, 11%). Overall, H. pylori was positive in 107 of 138 (77.5%) patients. There was a significant association of H. pylori with DU and NUD (p<0.000). Three-quarters of cases of normal endoscopy harbored H. pylori. The finding of 80% and 85% H. pylori in gastritis and duodenitis, respectively, was of interest(4).

3. Gastroesophageal reflux disease
In the study to determine the relationship between symptoms and H. pylori eradication and to determine whether H. pylori eradication results in symptoms or endoscopic findings of GERD, researchers at the University of Wisconsin Medical School, Milwaukee, showed that he presence of epigastric pain was significantly associated with persistent H. pylori infection 1 month after therapy (odds ratio 2.3, 95% CI: 1.02-5.2; P=0.041), as was nausea (OR 7.1, 95% CI: 0.93-55.6; P=0.029). The presence of epigastric pain was significantly associated with ulcer relapse at 6 months (OR 7.5, 95% CI: 3.6-15.7; P < 0.001) as was nausea (OR 5.1, 95% CI: 1.7-16.0; P=0.002). Heartburn was not associated with eradication of H. pylori or ulcer relapse. New onset reflux symptoms were reported by 17% (17 of 101 patients) at 6 months and were not significantly different in patients with (15%) and without (22%) persistent H. pylori infection (P=0.47)(5).

4. Parasitic infection
There is a report of a case of a 24-year-old male patient admitted for recent ascites and splenomegaly of unknown origin. The patient was referred to our institution with complaints of diarrhea, epigastric pain, abdominal cramping and weight loss over the past three weeks, Upper gastrointestinal system endoscopy performed a few days later revealed diffuse severe erythematous pangastritis and gastroduodenal gastric reflux. Duodenal biopsies showed chronic nonspecific duodenitis. Antrum and corpus biopsies showed chronic gastritis. The final diagnosis was consistent with parasitic infection while the clinical, sonographic and histological findings suggested an eosinophilic ascites(6).

5. Nucleic acids by phases of cavitary secretion
In the study of the concentration of nucleic acids in the cavitary secretion phase reflects the state of the gastroduodenal mucosa and physicochemical properties of the mucus of Sixty patients with gastroduodenal diseases (chronic gastritis, chronic duodenitis from surface to atrophic and during exacerbation), sgowed that changes in the distribution of nucleic acids by phases of cavitary secretion were revealed. A decrease in the total content of nucleic acids in cavitary contents was paralleled by decreased activity of chronic gastritis and duodenitis and normalization of colloid and gel-forming properties of the mucus(7)
6. Viral infection
In the study to investigate endoscopic and histopathological findings in the duodenum of patients with Strongyloides stercoralis (S. stercoralis) hyperinfection, reseachers at the indicated that twenty-four (96%) of the patients investigated were under immunocompromised condition which was mainly due to a human T lymphotropic virus type 1 (HTLV-1) infection. The abnormal endoscopic findings, mainly edematous mucosa, white villi and erythematous mucosa, were observed in 23 (92%) patients. The degree of duodenitis including villous atrophy/destruction and inflammatory cell infiltration corresponded to the severity of the endoscopic findings(8).

7. Celiac disease, Whipple's disease and Crohn's disease
In studied the count and identification of inflammatory cells in duodenal biopsies of specific duodenitis. In celiac disease there is an increase of lymphocytes in the epithelial layer, and rich population of plasmacells in the lamina propria of duodenal mucosa. In Whipple's disease the reticulum cell component of lamina propria is increased, while total inflammatory cells are within normal limits, and both lymphocytes and plasmacells are decreased. The comparison between duodenal and jejunal findings shows similar data in celiac and Whipple's disease. In Crohn's disease the inflammatory cell count differs from controls only in presence of radiological or endoscopical features of duodenal involvement(9).

8. Toothpick ingestion
There is a report of  two patients with duodenal inflammation secondary to toothpick ingestion. In the first patient, there was acute onset of severe abdominal pain, with findings on computed tomography consistent with marked duodenal inflammation. Endoscopy revealed a toothpick embedded in the wall of the duodenum with associated ulceration. In the second patient, 4 months of chronic abdominal pain was evaluated by upper endoscopy which revealed a toothpick embedded in a 1-cm ulcer found in the third portion of the duodenum(9a).



9. Etc.

B. Risk Factors 
1. Smoking and gender
In the study of the extent of duodenitis on the site opposite the ulcer determined by histological examination, showed that Sixty per cent of the duodenal ulcers were healed after three weeks. By univariate analysis, the following factors affect the healing; pain radiation to back and pain duration during treatment (p less than 0.001), multiple or deep ulcers, narrowing of duodenal bulb (p less than 0.01), number of pain attacks and poor appetite (p less than 0.05). By the stepwise logistic regression model, the following factors were selected as predictors for healing of duodenal ulcer with 76% correct classification: pain radiation to back (p = 0.002), deep ulcer (p = 0.013), multiple ulcers (p = 0.028). Number of cigarettes/day (p less than 0.007) and male sex (p = 0.036). By this model, the prediction of healing could be accurately assessed in 78% in a new sample. Individual treatment should be carried out on the basis of these factors(10).

2. Alcohol abuse 
Even though, there is  no any relation existing between the percentage of cases with atrophic inflammation and the kind of drinks or the content of ethanol in them, but examinations concerning the secretory function of the stomach showed lower values of hydrochloric acid secretion, both in basic conditions and after pentagastrin stimulation, in patients addicted to alcohol as compared to the control. Continuous abuse of alcohol predisposes to atrophic inflammation of the gastric mucosa, and the appearance of this type of inflammatory changes is related to the duration of addiction. The longer the addiction, the lower the secretion of hydrochloric acid is(11).

3. Stress
GDD in the young is a very frequent pathology, which may be triggered off by abrupt changes in life style, especially in those patients who are unable to react positively to changes in the outer world. GD pathology arises most frequently during the first five months of military service, especially within the third and the fourth month(12). 

4. Etc.
 
III. Diagnosis 
After taking the family history, recording the symptoms and a complete physical examination, the most common test which your doctor order is Endoscopy.
The aim of the test is to allow your doctor to visualize the duodenum and it surrounding area to check for any abnormality, including shallow, eroded areas in the wall of the intestine, bleeding, etc. 
In the study of 50 patients with endoscopically diagnosed duodenitis who had undergone double-contrast upper gastrointestinal (GI) examinations. Duodenitis was diagnosed on the original radiographic reports in six of 37 patients (16%) with mild-to-moderate duodenitis, five of 13 patients (38%) with severe duodenitis, and 11 of 50 patients (22%) with all grades of duodenitis on endoscopy. Subsequent analysis of the films revealed one or more radiologic signs of duodenitis (including folds more than 4 mm in thickness, mucosal nodularity, bulbar deformity, and erosions) in 18 of 37 patients (49%) with mild-to-moderate duodenitis, eight of 13 patients (62%) with severe duodenitis, and 26 of 50 patients (52%) with all grades of duodenitis on endoscopy(13),

IV. Complications
1. Hemorrhage
Inflammation of the stomach lining may lead to the formation of an ulcer (lesion) in the  the duodenum or stomach. In the study to investigate epidemiological, clinical, and etiological characteristics of acute upper gastro-intestinal bleeding between January 2003 and December 2008, researchers at the Medical Unit C, Ibn Sina Hospital, found that in 1389 registered cases, 66% of the patients were male, 34% were female. Mean age was 49. 12% of patients had a history of previous hemorrhage, and 26% had a history of NSAID and aspirin use. Endoscopy was performed in 96%. The gastroduodenal ulcer was the main etiology in 38%, followed by gastritis and duodenitis in 32.5%(14).

2. Iron deficiency anemia
Iron deficiency anemia is a result of internal bleeding. Men and postmenopausal women with iron deficiency anemia are routinely evaluated to exclude a gastrointestinal source of suspected internal bleeding. Forty-three of the 45 women fulfilled the entry criteria and were enrolled. Their mean age was 35 +/- 15 years and their mean hemoglobin level 9.3 +/- 2.3 g/dl. Twenty-eight upper gastrointestinal lesions were demonstrated in 24 of the 43 patients (55.8%): erosive gastritis in 12 (27.9%), erosive duodenitis in 4 (9.3%), erosive esophagitis in 3 (7.0%), hiatus hernia (with Cameron lesions) in 3 (7.0%), active duodenal ulcer in 1 (2.3%) and hyperplastic polyp (10 mm) in 1 (2.3%)(15).

3. Peritonitis
There is a report of a  case of a 62-year-old man with Candida krusei peritonitis secondary to duodenal perforation due to Candida duodenitis that was successfully treated with a 14-day course of caspofungin, according to Department of Human Pathology, University of Messina(16).

4. Etc.


IV. Prevention
A. The do`s and do not`s list
1. Avoiding spicy foods
Prolonged intake spicy foods incinerates the risk of irritation and inflammation of the lining of stomach and duodenum. 

2. Changes in food tolerance and lifestyle
If you develop Duodenitis as result of bacterial infection, changes in food tolerance and lifestyle can be helpful. The prevalence of food intolerance decreased from 71% to 44% among patients with peptic ulcer disease (PUD) (P < 0.0001) and from 76% to 63% among patients with  duodenitis (G/D) (P = 0.09). Tolerance improved for coffee, orange juice, fried foods, spicy foods and fruits, according to the study by Haukeland University Hospital(17).

3. Quit smoking
In the study to  investigate whether cigarette smoking has an additive effect on the clinical presentation and course of disease in Helicobacter pylori-positive dyspeptic patients, researchers at the  Tel Aviv University, indicated that Gastric and duodenal ulcers were significantly less prevalent in non-smokers than in current or past smokers (gastric 1.8%, 4.1%, 6.3%; duodenal 39.8%, 50%, 51.4%, respectively) (P < 0.05). The incidence of gastrointestinal bleeding was significantly lower in non-smokers than in current or past smokers (7.1%, 8.1% and 20.7%, respectively) (P < 0.05). Bacterial density, as assessed by the UBT value in 244 patients, was higher in non-smokers (mean 352.3 +/- 273 units) than in past smokers (mean 320.8 +/- 199) or current-smokers (mean 229.9 +/- 162) (P < 0.05)(18).

4.  Excessive alcohol drinking and stress
Excessive drinking and stress are associated with the risk of  Duodenitis(19)(20).

5. Avoiding prolonged use  of anti-inflammatory drugs, such as Ibuprofen and Aspirin
Prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin), naproxen (Aleve), or aspirin, in some people, it can lead to irritation causes of  inflammation in the lining of the duodenum(21).

6. Moderate exercise
Exercises can reduce stress at work and at home(22), thus, reducing the risk of Duodenitis.

7. Etc.

B. Phytochemicals to prevent Duodenitis
The aim of phytochemicals is to enhance the inmmue function ain fighting against invasion as result of  bacterial, viral and parasitic causes of inflammation
1. Gingerole
Gingerole, is also known as gingerol, a phytochemical of Flavonoids (polyphenols) found in fresh ginger. and in variety of other plants. The herb has been used to treat nausea and vomiting of pregnancy, motion sickness, rheumatoid arthritis, relieve migraine, etc. In the investigation of the effectiveness of chemical constituents of Zingiber officinale Rosc. (Zingiberaceae)in treating oxidative stress found that compounds [6]-gingerol, [8]-gingerol, [10]-gingerol and [6]-shogaol of the herb scavenges of 1,1-diphenyl-2-picyrlhydrazyl (DPPH), superoxide and hydroxyl radicals, inhibitsof N-formyl-methionyl-leucyl-phenylalanine (f-MLP) induced reactive oxygen species (ROS) production in human polymorphonuclear neutrophils (PMN), lipopolysaccharide induced nitrite and prostaglandin E(2) production in RAW 264.7 cells, according to the study of "Comparative antioxidant and anti-inflammatory effects of [6]-gingerol, [8]-gingerol, [10]-gingerol and [6]-shogaol" by Dugasani S, Pichika MR, Nadarajah VD, Balijepalli MK, Tandra S, Korlakunta JN(23).

2. Rutin
Rutin also known as rutoside, quercetin-3-O-rutinoside and sophorin is a Flavonols, belong to Flavonoids (polyphenols) of Phenolic compounds found orange, grapefruit, lemon, lime, berries mulberry, cranberries, buckwheat etc. In the investigation of Rutin, a natural flavone derivative and its anti inflammatory effect found that Oral administration of rutin reduced rat paw swelling starting 2 hours after lambda-carrageenan injection. Rutin reduced significantly (p < 0.05) and in a dose-dependant manner the polymorphonuclear neutrophils chemotaxis to fMet-Leu-Phe, according to the study of "Anti-inflammatory effect of rutin on rat paw oedema, and on neutrophils chemotaxis and degranulation" by Selloum L, Bouriche H, Tigrine C, Boudoukha C.(24).

3. Catechin
Catechin is phytochemical of Flavan-3-ols, in the group of Flavonoids (polyphenols), found abundantly in white tea, green tea, black tea, grapes, wine, apple juice, cocoa, lentils, etc. In the research on polyphenolic compounds (included catechins) in the berries of edible honeysuckle and their biological effects, including recommended utilization, are reviewed found that These berries seem to be prospective sources of health-supporting phytochemicals that exhibit beneficial anti-adherence and chemo-protective activities, thus they may provide protection against a number of chronic conditions, e.g., cancer, diabetes mellitus, tumour growth or cardiovascular and neurodegenerative diseases, according to "Phenolic profile of edible honeysuckle berries (genus lonicera) and their biological effects" by Jurikova T, Rop O, Mlcek J, Sochor J, Balla S, Szekeres L, Hegedusova A, Hubalek J, Adam V, Kizek R.(25). Also in the preparation of the gel of Chinese medicine catechu, and to observe the release mechanism in vitro and anti-inflammatory activity in rats, found that the optimum condition of extraction from catechu was as follows, the concentration of ethanol, ratio of raw material to solvent, ultrasonic time, and extraction temperature were 50% , 1: 12, 35 min and 60 degrees C, respectively. The formulation of catechu gel was carbomer-9 400.5 g, glycerol 5.0 g, the extracts of catechu 50.0 mL, and triethanomine 0.5 mL The gel was semitransparent and stable. The drugs released quickly. The catechu gel reduced the paw edema considerably in dose-dependent manner compared to carrageenan-induced rat, according to "[Preparation and pharmacodynamics studies on anti-inflammatory effect of catechu gel].[Article in Chinese]" by Zheng X, Zheng C.(26).

4. Cinnamic acid
Cinnamic acid is a phytochemical in the class of Hydroxycinnamic acids, found abundantly in cinnamon, aloe. etc. In the sudy of the ulcer-preventive properties of aqueous extract of ginger rhizome (GRAE) belonging to the family Zingiberceae, found that compositional analysis favored by determination of the efficacy of individual phenolic acids towards their potential ulcer-preventive ability revealed that between cinnamic (50%) and gallic (46%) phenolic acids, cinnamic acid appear to contribute to better H(+), K(+)-ATPase and Helicobacter pylori inhibitory activity, while gallic acid contributes significantly to anti-oxidant activity, according to "Gastroprotective Effect of Ginger Rhizome (Zingiber officinale) Extract: Role of Gallic Acid and Cinnamic Acid in H+, K+-ATPase/H. pylori Inhibition and Anti-oxidative Mechanism" by Nanjundaiah SM, Annaiah HN, M Dharmesh S.(27).

5. Resveratrol
Resveratrol is a phytochemical in the class of Stilbenoids, found abundantly in skins and seed of grape wine, nuts, peanuts, etc. In the observation of Resveratrol's effects in exhibition of several physiological activities including anticancer and anti-inflammatory activities in vitro and in experimental animal models, as well as in humans, found that Anticancer activity of this compound is mainly due to induction of apoptosis via several pathways, as well as alteration of gene expressions, all leading to a decrease in tumor initiation, promotion, and progression. Resveratrol exhibits anti-inflammatory activity through modulation of enzymes and pathways that produce mediators of inflammation and also induction of programmed cell death in activated immune cells. Resveratrol has been shown to produce no adverse effects, even when consumed at high concentrations, according to "Potential of resveratrol in anticancer and anti-inflammatory therapy" by Udenigwe CC, Ramprasath VR, Aluko RE, Jones PJ.(28). Also in the study of implantation and growth of metastatic cancer cells at distant organs is promoted by inflammation-dependent mechanism, found that resveratrol remarkably inhibited hepatic retention and metastatic growth of melanoma cells by 50% and 75%, respectively. The mechanism involved IL-18 blockade at three levels: First, resveratrol prevented IL-18 augmentation in the blood of melanoma cell-infiltrated livers. Second, resveratrol inhibited IL-18-dependent expression of VCAM-1 by tumor-activated hepatic sinusoidal endothelium, preventing melanoma cell adhesion to the microvasculature. Third, resveratrol inhibited adhesion- and proliferation-stimulating effects of IL-18 on metastatic melanoma cells through hydrogen peroxide-dependent nuclear factor-kappaB translocation blockade on these cells, according to "Resveratrol prevents inflammation-dependent hepatic melanoma metastasis by inhibiting the secretion and effects of interleukin-18" by Salado C, Olaso E, Gallot N, Valcarcel M, Egilegor E, Mendoza L, Vidal-Vanaclocha F.(29).

6. Etc.
C. Antioxidant to prevent Duodenitis
The aim of antioxidants is to enhance the inmmue function ain fighting against invasion as result of bacterial, viral and parasitic causes of inflammation.
1. Quercetin
Since it contains high amount of antioxidants, onion enhances the immune system in fighting against the forming of free radicals and foreign invasion, thus eeducing the symptoms of inflammatory conditions such as arthritis and gout and infection caused by bacteria, including E.coli and salmonella,etc., according to the study of Antibacterial and antioxidant activities of quercetin oxidation products from yellow onion (Allium cepa) skin.(30).

2. Bromelain
Today Pineapple is widely cultivated for commercial and its rich of vitamins and mineral and digesting enzyme bromelin which seems to help digestion at the end of a high protein meal. It is second only to banana as America's most favourite tropical fruit. In the classification of bromelain is a mixture of proteinases derived from pineapple stem and its effect in gastrointestinal tract, found that bromelain enzymes can remain intact and proteolytically active within the murine gastrointestinal tract. They provide further support for the hypothesis that oral bromelain may potentially modify inflammation within the gastrointestinal tract via local proteolytic activity within the colonic microenvironment, according to "Proteolytic activity and immunogenicity of oral bromelain within the gastrointestinal tract of mice" by Hale LP.(31). Also Bromelain also increases the immune function in fighting the invasion of foreign substances such as bacteria and virus, thus decreasing the risk of inflammation and infection according to the study of "Bromelain treatment reduces CD25 expression on activated CD4+ T cells in vitro" by Secor ER Jr, Singh A, Guernsey LA, McNamara JT, Zhan L, Maulik N, Thrall RS., posted in PubMed(32).

3. Polyphenols
Polyphenols, one of more powerful form of antioxidant not only helps to improve the immune system fighting against the forming of free radicals and guarding our body from foreign invasion, such as virus and bacteria, thus reducing the risk of inflammation and lessening the risk of oxidation of low-density lipoprotein (LDL) cause coronary heart disease, according to the study of "Plant polyphenols as dietary antioxidants in human health and disease" by Kanti Bhooshan Pandey and Syed Ibrahim Rizvi, posted in PubMed Central(33).

4. Catechins
Catechins are a category of polyphenols contained epicatechin (EC), epigallocatechin (EGC), epicatechin gallate (ECG) and epigallocatechin gallate (EGCG) and 25-100 times more potent than vitamins C and E that help to protect the body from oxidative damage by enhancing the immune function in fighting against forming of free radicals cause of cancer, according to the study of "Green tea catechins augment the antitumor activity of doxorubicin in an in vivo mouse model for chemoresistant liver cancer" by Liang G, Tang A, Lin X, Li L, Zhang S, Huang Z, Tang H, Li QQ.(34).

5. LycopeneLycopene, one of the powerful antioxidant in tomatoes, not only helps the immune system in neutralizing the forming of free radicals in the body and according to Harvard investigation as it found that men who ate more than 10 servings tomato-based foods daily (like cooked tomatoes and tomato sauce,) had a 35 percent lower risk of developing prostate cancer than those who ate the least amount of these foods. The benefits of lycopene was more pronounced with advanced stages of prostate cancer. Also according to the study of "Chemoprevention of prostate cancer with lycopene in the TRAMP model" by Konijeti R, Henning S, Moro A, Sheikh A, Elashoff D, Shapiro A, Ku M, Said JW, Heber D, Cohen P, Aronson WJ.(35),.

6. Etc.

D. Diet to prevent Duodentitis
1. Purple grape juices
In the evaluation of the protection of organic and conventional purple grape juices and theirs effect against the oxidative damage provoked by carbon tetrachloride (CCl(4)) found that in the alkaline version of the comet assay performed on whole blood, it was observed that CCl(4) was capable of inducing mainly DNA damage class 4 and 3 frequencies, which was significantly reduced in groups that received both purple grape juices. This implies that both grape juices have an important antigenotoxic activity, according to "Antioxidant and antigenotoxic activities of purple grape juice--organic and conventional--in adult rats" by Dani C, Oliboni LS, Umezu FM, Pasquali MA, Salvador M, Moreira JC, Henriques JA(36).

2. Garden strawberry
In the observation of Ethanolic extract of Fragaria vesca (EFFV) of Fragaria vesca L. and its effect on Ulcerative colitis and Crohn's disease (chronic recurrent inflammatory bowel disease (IBD)) found that EFFV at 500 mg/kg showed significant amelioration of experimentally induced IBD, which may be attributed to its antioxidant and anti-inflammatory properties, according to "Effect of fruit extract of Fragaria vesca L. on experimentally induced inflammatory bowel disease in albino rats" by Kanodia L, Borgohain M, Das S.(37).

3. Lime
Since it contains high amount of flavonoid, it helps to improve the immune system fighting against forming of free radical causes of tumor and cancer, according to the study of "Dietary intake of selected flavonols, flavones, and flavonoid-rich foods and risk of cancer in middle-aged and older women" by Wang L, Lee IM, Zhang SM, Blumberg JB, Buring JE, Sesso HD.(38).

4. Papaya leaves
In the assessment of ethanolic extract of Carica papaya leaves and its anti-inflammatory activity effect found that the extracts significantly reduced the persistent oedema from the 4th day to the 10th day of the investigation. The extracts also produced slight mucosal irritation at high doses. The study establishes the anti-inflammatory activity of Carica papaya leaves, according to "Anti-inflammatory activities of ethanolic extract of Carica papaya leaves" by Owoyele BV, Adebukola OM, Funmilayo AA, Soladoye AO.(39).

5. Celery
High amount of vitamin C in celery helps to increase the immune function infighting against the forming of free radicals, and irregular cell growth causes of tumor and cancer, according to the study of "Vitamin C and cancer: what can we conclude--1,609 patients and 33 years later?" by Cabanillas F.(40). Also High amount of flavonoid in celery helps to reduce the risk of oxidative stress as a result of its antioxidant activity, according to the study of "Influence of flavonoid extracts from celery on oxidative stress induced by dichlorvos in rats" by Cao J, Zhang X, Wang Q, Jia L, Zhang Y, Zhao X.(41).

6. Etc.
 
V. Treatment
A. In conventional medicine perspective
A.1. Antibiotics
If the causes of the disease is as a result of bacterial infection, then antibiotic is the primary choice of treatment such as, Amoxicillin, Clarithromycin (Biaxin), Metronidazole (Flagyl), etc. for 14 days to prevent re-infection or recurrence. In the study to assess the duodenal infection by Mycobacterium avium-intracellulare is a common opportunistic disease in HIV-infected patients (Individuals with CD4 counts <50 cells/mm3 are at highest risk) found that the patient was treated with rifampicine, isoniazide, ethambutol, and pyrazinamide in association with stavudine, lamuvidine and efavirenz. Despite improvement of general condition, fever persisted and the patient died after 40 days of treatment. The main symptoms are diarrhea, abdominal pain, weight loss, and fever(41a).
 Other in the study of the prevalence of Helicobacter pylori infection in patients with erosive duodenitis (ED), the associated gastric histological lesions and their response to eradication therapy with omeprazole plus two antibiotics, showed that a 1-week twice daily therapy with omeprazole plus two antibiotics (clarithromycin plus amoxycillin or metronidazole) was very effective in H. pylori eradication, duodenal erosion healing, symptomatic improvement, and in disappearance of associated histological gastritis. These observations suggest that ED should be considered a variant form of duodenal ulcer disease and treated accordingly(41b).
Side effects include yeast overgrowth,  gastrointestinal trouble, etc.

A.2. Of the causes of the disease is as a result of elevated stomach acid, then  medication include
1. Proton pump inhibitors
 According to the study by Uniwersytet Mikołaja Kopernika w Toruniu, Collegium Medicum w Bydgoszczy, Proton pump inhibitors (PPI), are characterized by high effectiveness, selectivity and few adverse events. Development of PPI was an important issue in aspect of acid-related diseases treatment. Nowadays following PPI are available on the market: omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole. In children these drugs are the most frequently use in gastritis and duodenitis, ulcer disease with coexistence of Helicobacter pylori infection and gastroesophageal reflux disease. Pharmacokinetics of PPI is slightly different in children than in adults and so far there is a lack of randomised studies assessing the efficacy of PPI i developmental period medicine on numerous groups of patients(41c).
Side effects include nausea, diarrhea, abdominal pain, fatigue, dizziness, etc.

2. Histamine H2-receptor antagonists
Histamine H2-receptor antagonists, such as, Cimetidine (Tagamet), Famotidine (Pepcid), Nizatidine (Axid), etc.
According to the study by Dr. Mackinnon M and research team, treatment with cimetidine for 6 weeks resulted in a significant improvement in symptoms and in the endoscopic appearance of the duodenitis when compared to treatment with placebo. The symptomatic and endoscopic improvement, however, was not associated with any significant change in the histological grading of the duodenitis.
Side effects include headache, tiredness, dizziness, confusion, diarrhea, constipation, rash, etc(41d).

According to the Department of Family Medicine, Cathay General Hospital, Taipei, Taiwan, in the study of all the patients aged ≥ 20 years with a diagnosis of cirrhosis hospitalized for variceal bleeding and non-variceal upper GI adverse events (oesophageal, gastric, duodenal ulcer, bleeding; gastritis and duodenitis) in 2006, using ICD-9-CM diagnosis codes from inpatient claims from the Taiwan National Health Insurance Database, found that Concomitant use of proton pump inhibitors and histamine-2 receptor antagonists tended to decrease the upper GI toxicity associated with non-selective NSAIDs and celecoxib(41f).

3. Proton pump inhibitors and low-dose aspirin
In the study to investigate the effect of histamin H₂ receptor antagonist (H₂RA) or proton pump inhibitor (PPI) for the prevention of upper gastrointestinal lesions associated with low-dose aspirin, found that suggest that the combined administration of low-dose aspirin and PPI is effective for the prevention of upper gastrointestinal lesions associated with low-dose aspirin. Also, the pharmacists should be especially careful for upper gastrointestinal lesions development within two years after administration of low-dose aspirin, regardless of combined whether H₂RA or PPI(41e).

B. In herbal medicine perspective
1. Herbal combination of Symphitum officinalis and Calendula officinalis
In a study of a total of 170 patients were treated--137 only with the herb combination of Symphitum officinalis and Calendula officinalis of (78 with duodenal ulcer and 59 with gastroduodenitis), 33--with the herb combination together with antacid (21 with duodenal ulcer and 12 with gastroduodenitis), Dr. Chakŭrski I and the team found that the spontaneous pains disappeared in 90 per cent of the patients--in the group with and in the group without antacid, the dyspeptic complaints faded in over 85 per cent but in the patients, treated with herbs and antacid the mentioned complaints disappeared several days earlier. The palpitation pains, in both groups, disappeared in more than 90 per cent of the patients within the same time. Gastric acidity, in both groups, showed a statistically insignificant tendency to decrease prior and post treatment. The gastroscopically control revealed that the ulcer niche, in both groups, was healed in almost the same percentage of the patients(42)

2. Suggested Starting Formula(43)
Aloe vera juice 70 wt%
Cabbage juice 20 wt%
Honey 10 wt%
Dosage: 3 times a day before meal

C. In traditional Chinese medicine perspective
According to the article of Herbs and Foods to Help Cure Naturally by NFA clinic of Oriental Medicine, epigastric pain including peptic ulcers is mostly the result of metabolic imbalance among liver, stomach and spleen. The function of one organ is depending on the function of another organs in Oriental medicine. They are understood not only by its function but also by its relationship with others. The article also suggested that Lu Hui, Yi Tang are ideal herbs to treat peptic ulcers
1. Lu Hui (Aloe Vera), the bitter and cold herb has been used in TCM to drain fire and guides out accumulation: for (chronic) constipation, strengthens the Stomach and kills parasites, clears heat and cools the Liver: for epigastric discomfort, enhancinmg the functions of Large Intestine, Liver, Stomach channels. Cautions: due to its cold property, dosage should be made considering the constitution of each patients. Some persons show allergy reaction to aloe vera

2. Yi tang (Honey), the sweet, slightly warm herb has been sued in TCM to tonifie the Spleen,  the middle burner Qi (stomach and spleen), alleviate pain, moisten the Lungs and stops cough by enhancing the functions of Lung, Spleen, Stomach channels.

3. Gan Cao (Licorice) the sweet and neutral herb has been used in TCM to tonifie the Spleen, moisten the Lungs, stop coughing, clear heat and relieves fire toxicity, moderates spasms and alleviates pain, by enhancing the functions of all 12 channels(42).

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