Medical management of peptic ulcer.

Sir Francis Avery Jones (FAJ-for once the abbreviation means something to everyone) has been actively involved in the practical and research aspects of management of peptic ulcer throughout his long and productive career. Some of FAJ's earliest publications (Avery Jones, 1939a and b, 1943, 1947) deal with management of acute upper alimentary bleeding and he was instrumental in introducing modern concepts of fluid and electrolyte balance into the treatment of these acutely ill patients. Accurate diagnosis was always one of FAJ's interests and in addition to exploiting together with F. Pygott the potential of the emergency barium meal, he did research in the field of endoscopy (Fletcher and Avery Jones, 1945). The endoscopy sessions at Central Middlesex Hospital, before the introduction of fibreoptic instruments made life much easier for practitioners of this art, were one of the focal points of the week, with FAJ enjoying the doing and the teaching, usually with a large group of acolytes in attendance. FAJ's contribution in the peptic ulcer area include not only research into the treatment and prognosis of complications of the disease (Avery Jones and Doll 1953; Avery Jones, 1956), but he also encouraged the then novel and revolutionary approach to the statistical evaluation of the results of treatment through the controlled therapeutic trial. Working in the Department of Gastroenterology at Central Middlesex Hospital Dr (now Sir) Richard Doll was given facilities to conduct the studies that eventually culminated in evaluating the first agent shown to significantly accelerate the healing of gastric ulcer (GU)-carbenoxolone sodium (Doll et aL, 1962). Environmental factors, such as smoking, were also investigated (Doll, Avery Jones and Pygott, 1958) and FAJ's sustained interest in carbenoxolone is documented in serial publications (Avery Jones and Sullivan, 1972; Avery Jones and Parke, 1975; Avery Jones, Langman and Mann, 1978). These important researches established the background for the rapid progress and far-reaching changes in management of peptic ulcer that have taken place during the past 10 years. Progress in this area has been due to several factors. The development of fibreoptic endoscopy has improved the accuracy of diagnosis and the assessment of the effects of treatment on the healing of ulcers. The use of controlled clinical trials for evaluation of treatment has lead to a vast accumulation of data on ulcer healing under various medical regimes. Only those trials which take complete ulcer healing as the endpoint of treatment should be considered as valid. This is because endoscopic measurements of ulcer size are inaccurate and also because a partly healed ulcer is a doubtful therapeutic benefit. Further progress in the medical management of duodenal ulcer (DU) and GU has been due to a fresh interest in the pharmacology of ulcer-healing drugs. The development of agents that powerfully inhibit gastric acid secretion by blocking the action of endogenous histamine at H2 receptors, or by blocking H+K+ATPase in parietal cells has led to intense research activity. This has produced a wealth of new data, new drugs and new insights into older remedies, sometimes with unexpected results. Faster healing of DU or GU is now attainable with many drugs. Moreover, medical treatment has for the first time been able to decrease significantly the relapse rate of DU and GU. The number of therapeutic strategies available for the management of DU or GU has increased, making the decision making process more interesting, but also more difficult.