Evidence for an infarctive pathogenesis of acute and chronic gastroduodenal ulceration

It is clear that all mucosal defensive mechanisms acting against aggressive ulcerogenic factors depend on adequate blood flow. When defence is active, ulcers tend to heal and do so faster when luminal aggression is prevented by reduction of acidity or eradication of H. pylori. Such successful treatment is so profitable that pharmaceutical companies invest vast fortunes on research into every aspect of therapy. This may explain why research on basic aetiology has been slower. Nevertheless there have been recent advances which increasingly point towards an ischaemic pathogenesis of both acute and chronic ulcers. We have been studying those ischaemic mechanisms that may be triggered by alteration of normal physiological processes, and we now have a body of evidence supporting an infarction-like mechanism induced by abnormal motility which might explain the initiation of both acute and chronic human ulceration. In this article we review the evidence for this and show that such a pathogenesis is compatible with the features and current concepts of gastro-duodenal ulceration. Perhaps the most striking feature of chronic ulcers is their singularity, and localisation to the lesser curvature and first part of the duodenum. Within the lesser curvature there is an increasing incidence from the oesophageal end towards pylorus, with maximal incidence in the incisural area (1). Duodenal ulcers occur on the anterior or posterior walls of the first 4 cm. uncommonly on the superior "cap" and rarely on the inferior wall. Such localisation points to a primary cause which, by analogy with other localised necroses eg coronary or stroke, is usually an infarction of an end-artery system.