Journal of Gastroenterology and Hepatology (1992) 7, 427-431

SPECIAL ARTICLE

Duodenal ulcer in China F. I. TOVEY Department of Surgery, University College London, London UK

Abstract The author visited China in 1981 and 1984 and obtained data comparing the incidence of duodenal ulcer in the rice eating districts of the south with the incidence in the wheat, maize and millet eating areas of the north. The evidence suggested a higher prevalence of duodenal ulcer in the rice eating areas than in the wheat eating areas, and a low prevalence in association with millet eating. However, the differences were less marked than between similar rice and wheat eating areas of India. It is suggested that the lower prevalence of duodenal ulcer in the wheat eating areas of north India compared with the rice eating areas of south India may be due in part to the mucosal protective effect of wheat bran in the unrefined wheat that is used in making chappatis. In China white refined flour is used in the making of steamed bread with the loss of any protective effect of wheat bran.

DUODENAL ULCER IN CHINA In India and Bangladesh the distribution of duodenal ulcer (DU) follows a dietary pattern and is more common in the rice, tapioca or sorghum eating areas.' It is relatively uncommon where unrefined wheat is the staple food. These areas are in the north, whereas the rice eating areas are in the south, extending upwards along the west coast and also the east coast onwards into Bangladesh and central Assam. Duodenal ulcer is also uncommon in some of the areas where millet or pulse are eaten. Likewise in Africa there are regions of high and low incidence, the incidence being low in millet eating areas and also where unrefined maize is eaten.* In the high prevalence rural areas of India and Africa duodenal ulceration has certain characteristics that differ from Western countries. The most common complication is pyloric stenosis. Haemorrhage and perforation are uncommon. There is a marked male predominance, and the ratio of DU to gastric ulcer (GU) is high. In the urban population the characteristics change and are similar to those in the West, with a high incidence of haemorrhage and perforation and a low incidence of pyloric obstruction. The male predominance becomes less and the ratio of duodenal to gastric ulcer is lower. T h e pattern suggests that a dietary factor is responsible for the differences in prevalence in rural areas and that where populations are subjected to the additional factor of the strains and stresses of urban life, a more acute type of ulcer occurs. In China there is a similar north-south geographic distribution of staple foods to that in India, with rice predominating in south and central China and wheat,

millets and maize in the north. With this in mind two visits were made, one in 1981 and a second in 1984 to try to find out whether the prevalence of DU varied in the same way as in India. In the absence of population surveys and hard statistical figures, one of the most useful sources of information was the impression among clinical workers in a given area as to whether a particular disease constituted a major or minor problem in their practice. Care was taken that the facilities and experience of the clinicians from different areas were comparable. It was of particular value whenever a clinician had worked in two different areas and had found a disease to be much more common in one of them. Where available hospital admission figures were useful, particularly when hospitals with similar facilities were compared. Often the number of cases had to be related to total hospital admissions including maternity, gynaecological and paediatric patients, but information was of more value wherever it was possible to ascertain the total number of actual medical and surgical admissions separately. In the case of peptic ulcer the number of surgical admissions for complications is a valuable index of the overall occurrence in the community. The 1981 visit was to mostly rice eating areas and also to Beijing which has a mixed cosmopolitan diet. The visit included Hangzhou, Shanghai, Wuhan, Kunming and Guangzhou. It was at a time when medical work in China was still undergoing reorganization following the Cultural Revolution. Consistent impressions about the extent of the DU problem in different areas were available, but there was very little supporting statistical information relating to hospital admission rates or endoscopy findings.

The results of survey made in 1981 and 1984. Correspondence: F. I. Tovey, University College London, Department of Surgery, The Rayne Institute, University Street, London WClE SJJ, United Kingdom. Accepted for publication 28 January 1992.

F. I. Tovey

428

and maize growing areas, so comparison with the rice growing areas was not possible. An unusually high percentage of positive findings was felt to be of significance, as was a high ratio of D U to GU, particularly if these findings were associated with a high admission rate.

i

Beijinp

RESULTS

Figure 1 Map of China showing the major towns visited in 1981 and.1984.

In 1984 the emphasis was laid on visiting wheat, millet and maize eating areas. The tour starting from Beijing included Lanzhou and areas to its south and east in Gansu Province, Xian, Taiyan and Changzhi in Shanxi Province, Zhengzhou and Shenyang (Fig. 1). On both visits information was sought about the prevalence and characteristics of DU and GU, and any differences with regard to prevalence and complications between rural and urban populations. Pyloric channel ulcers were included in the overall figures for GU. Figures for combined D U and G U were available in only two centres. In 1984 there was more statistical information available from endoscopy findings but these needed careful interpretation as an index of actual prevalence because of the variability in facilities, referral patterns and patient selection. These figures were largely from the wheat, millet

Duodenal ulceration was found to be a problem in all the areas during both visits. The prevalence was high in both the rice and wheat eating areas, but there was a consistent impression that it was higher in the rice eating areas (Table 1). This was supported by hospital admission figures from Guangdong Province (rice eating), Shandong Province (wheat eating) and Zhengzhou Province (wheat eating), giving the relationship between peptic ulcer admissions and total medical and surgical admissions (Table 2). Other figures related peptic ulcer admissions to total admissions from Lanzhou, Taiyuan and Beijing. It was difficult to evaluate the effect of a millet diet on duodenal ulceration because the diet in most of the traditional millet growing areas had become more mixed with more maize growing and the importation of wheat and rice. The information that was obtained suggested a lower prevalence in the millet eating areas. T h e type of millet also varied. In northern Shanxi (Datong) a rather glutinous Broomcorn millet (Panicum miliaceum) was grown, whereas in southern Shanxi and in Gansu a variety of Setaria italica was more common. In southern Shanxi, during the past 3 years, there had been a change from a harder to a softer variety of Setaria italica. T h e endoscopy figures from Shanxi Province showed a much higher percentage of endoscopies positive for DU in Datong in the north of the province (mixed diet: maize, oatmeal, Rroomcorn millet, wheat) and a low percentage in Changzhi in the south east (predominantly millet

Table 1 Duodenal ulcer: No statistics but consistent hospital reports _____

Diet

Place

Year

Major problem (DU : GU)

v ( 3 : 1)

Rice

Shanghai (4 hospitals)

1981

Rice Rice

Hangzhou (2 hospitals) Wuhan 1st Affiliated 2nd Affiliated Guangdong Xian (2 hospitals) Kunming (2 hospitals)

1981

Shenyang

1984

Yuling (N. Shaanxi) Chaoyang (W. Liaoning) Tangshan (Hebei)

1984

Rice Wheat Mixed (Rice, wheat, maize) Mixed (Rice, wheat) Millet eaters Maize + + +, millet + + Maize. millet

1981 1981 1984 1981

Moderate problem

r/

v ( 5 : 1) (2 : 1) v v

v v

Minor problem

Duodenal ulcer in China Table 2

429

Hospital admissions for peptic ulcer

Diet

Place Peptic ulcer

Rice

Rice+ + Wheat +

Guangdong 1979 (Surg & Med Adm) Jiangxi Prov 1981 (Survey Several Hospitals; Surg & Med Adm) Anshan (Liaoning Prov) (Surg & Med Adm)

+

Wheat

Mixed (Wheat, rice)

Millet + + + Wheat + Maize + Maize+ + Millet + + (Rural) Wheat+ + Rice+ + (Urban) Millet + + Wheat+ + Previously Wheat+ + Rice Millet

Now Millet + Maize Rice Wheat Sorghum

+++

Maize + Rice +

+

GU

4.1

1.03

3.97 : 1

0.81

1.59 : 1

0.47

3.57 : 1

0.61

2.12 : 1

7.0

2.18

1.28

2.15

1.68

Lanzhou 1960-64 (Total Adm) Military Hosp 1980-84 Taiyuan (Total Adm) Ba Meal 1971 +ve 1976 Endoscopy 1977 +ve 1983 1984

2.35

combined 0.05

1.3-1.6 : 1

6.3 3.5 1.9 0.9 2.1 : 1 1.91

Friendship Hospital (1980) 28 year average (Beds limited; Total Adm) Shiyan (NW Hubei; Total Adm)

0.83 0.15

Linchuan (1983) (Shanxi Prov; Total Adm) Changzi (1980-83) (Shanxi Prov; Total Adm)

0.5

2.4 : 1

0.51 0.1 1

0.32 0.04

1.6 : 1 2.75 : 1

0.38

0.26

0.13

2:l

0.53

0.17

0.30

1 : 1.8

1.2 combined 0.2

1.38

1.5

All Adm 0.0095 Mostly DU

Dietary survey shows less in millet eaters

Med 0.0187 Surg 0.046

Shenyang (1952-62; Japanese Occupation) (Total Adm) 1974-82

0.5

Adm: Administration; Med: Medical; Surg: Surgical.

1.30

perforation > stenosis). It is interesting that Keith Gillison, a surgeon who worked in the Union Hospital, Hankow, for many years before 1951, reported that pyloric stenosis was much more common then than haemorrhage or perforation.

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A higher male :female ratio (19 : 1) was reported from Datong in Shanxi Province where the percentage of positive endoscopy findings of Du was high. As mentioned, the ratio of D U to G U was reversed in the millet growing areas where there was a lower D U prevalence. A higher seasonal incidence in cold weather was reported in several centres.

CONCLUSIONS Although the information suggests a reduced prevalence of duodenal ulcer in the wheat growing areas, there is not the marked north-south difference between the wheat and rice eating areas that is reported from India. A reason for this may lie in the fact that white wheat flour has to be used in the making of steamed bread. This means that the wheat used in China has to be refined, whereas the wheat used in India to make chappatis is unrefined. There is evidence from animal peptic ulcer models that wheat bran contains a potent protective factor against peptic

Table 3 Complications of duodenal ulcer Place and date Beijing 1981 Capital Hospital Friendship Hospital Shanghai 1981 1st People’s Hospital Ruijin Hospital Shiyan 1970-81 NW Hubei Wuhan 1981 2nd Teaching Hospital Before 1950 (country people) Guangzhou 1981 People’s Hospital Survey N Hebei, Shanxi, Neirnong 1984 Lanzhou 1960-64 2nd Hospital 1984

Changzhi 1984 Linchuan 1984

Zhengzhou 1984 (PU Adm)

Haemorrhage + + > perforation > obstruction Haemorrhage + + > perforation > obstruction Haemorrhage + + > perforation > obstruction Haemorrhage + + > perforation > obstruction Haemorrhage > stenosis > perforation Haemorrhage > perforation > obstruction Stenosis > haemorrhage > perforation Haemorrhage > perforation > obstruction Haemorrhagc (18.9%) Perforation (1.7%) Stenosis (2.2%) Haemorrhage > perforation > obstruction Haemorrhage (49.5%) Perforation (30.4%) Obstruction (14.6%) Perforation + haernorrhage (4.6%) Haemorrhage + + + perforation + obstruction + Haemorrhage (20/year) Perforation (lO/year) Obstruction (very few) Haemorrhage (40.2%) Perforation (23.2%) Obstruction (16%)

Duodenal ulcer in China ~ l c e r a t i o n . ~T- h~e lack of this in China may be an explanation of the difference in prevalence of duodenal ulceration between the wheat eating areas of China and India. As in both India and Africa the information does support a low prevalence in areas where certain millets are the staple food.

ACKNOWLEDGEMENTS The author thanks Professor Chen Minzhang, Minister of Public Health, for all the careful detailed arrangements he made for both the visits to China, and to the welcome given by so many friends and colleagues in the places visited, who went to great trouble to extract information about peptic ulceration from their records.

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REFERENCES 1. TOVEY F. I. Peptic ulcer in India and Bangladesh. Gut 1979; 20: 329-47. 2. TOVEY F. I. & TUNSTALL M. Duodenal ulcer in black populations in Africa south of the Sahara. Gut 1975; 16: 564-76. 3. JAYARAj A. P., TOVEY F. I. & CLARKC. G. Possible dietary factors in relation to the distribution of duodenal ulcer in India and Bangladesh. Gut 1980; 21: 1068-76. 4. TOVEY F. I, JAYARAj A. P. & CLARK C. G. Fibre and duodenal ulcers. Lancer 1982; u: 879. 5 . TOVEY F. I. & JAYARAJ A. P. Peptic ulcer in India. Gut 1990; 31: 123. F. I. & JAYARAJ A. P. Duodenal ulcer and carbo6. TOVEY hydrates. Gut 1991; 32: 339.

Duodenal ulcer in China.

The author visited China in 1981 and 1984 and obtained data comparing the incidence of duodenal ulcer in the rice eating districts of the south with t...
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