Antral Ulcers Research Articles

Perforated gastric trichobezoar: A Case Report

Case of a 16-year-old female who presented with an acute abdomen secondary to perforated viscous. At laparotomy, a perforated gastric ulcer secondary to a big gastric trichobezoar was found. Gastrotomy, extraction of the trichobezoar and oversewing the perforation with an omental patch was carried out. The patient admitted postoperatively to trichotillomania and trichophagia up to 6 years previously. She had an uneventful post-operative recovery and was discharged well. INTRODUCTION A bezoar is a ball of swallowed foreign material (usually hair or fiber) that collects in the stomach and fails to pass through the intestines. The term “bezoar” is derived from Arabic badzehr or from Persian panzehr, both meaning counter poison or antidote (1,2). Although the prevalence of bezoars in humans is low, if treatment is not administered, associated mortality rates may be as high as 30% primarily because of gastrointestinal bleeding, destruction, or perforation (1). Bezoars often develop after gastric operations that alter the motility or emptying of the stomach. However, they are most common in children and adolescents with normal gastrointestinal function and usually result from an underlying behavioral disorder. In the classic review by DeBakey and Ochsner (3), 80% of trichobezoars were found in patients younger than 30 years of age. CASE REPORT A 16-year-old female presented to causality with a complaint of epigastric pain for the past 3 days. The pain woke her up from her sleep. She also vomited about 10 times since that morning. Past medical history included a previous admission for similar kind of pain that was treated as possible peptic ulcer disease. A gastroscopy was planned but was not done. She also had past history of “irritable bowel syndrome” (IBS) and a left groin hernia repair 10 years previously. On examination, the patient was found to have a pulse rate of 98/min, blood pressure of 80/40 mm Hg, respiratory rate of 16/min and a temperature of 37.3 degrees Centigrade. Abdominal examination confirmed an acute abdomen. The rest of the examination was unremarkable. Investigations showed haemoglobin 13.3 g/dl, white cell count 17.1 x 109/l, urea & electrolytes and liver function tests were normal. CRP was 103 mg/l. An erect chest x-ray showed pneumoperitoneum. Abdominal x-ray was unremarkable. The patient was prepared for urgent surgery. At laparotomy, she was found to have a perforation in the anterior wall of the gastric antrum close to the lesser curve (figure 1). Figure 1 Figure 1: Antral perforated gastric ulcer A large mass could be felt in the stomach. Therefore gastrotomy was done (figure 2) which revealed a large trichobezoar occupying nearly the whole lumen of the stomach (figure 3). Perforated gastric trichobezoar: A Case Report 2 of 3 Figure 2 Figure 2: Trichobezoar being extracted through a gastrotomy Figure 3 Figure 3: The Trichobezoar. Note: it is cast in the shape of the stomach This was extracted, the perforation was oversewn with an omental patch and the gastrotomy was then closed in two layers. Finally, the peritoneal cavity was washed with normal saline. The patient had an uneventful post-operative recovery. She confessed to both trichotillomania and trichophagia in the past but insisted that it stopped 6 years prior to admission. Her father who was made aware of the condition acknowledged this. She was discharged well and followedup 6 weeks later in the outpatients' department with no complaint. DISCUSSION Our patient suffered from trichotillomania, a type of pica that was first described in 1889 as an irresistible urge to pull one's hair (4), and subsequent trichophagia, the oral ingestion of hair. Among those who suffer from trichotillomania, only 30% will engage in trichophagia, or eating their hair, and of these, only some 1% will go on to eat their hair to the extent requiring surgical removal (5). Trichobezoars may result in a range of gastrointestinal symptoms or may be asymptomatic (3,6). Clinical features may include anorexia, bloating, early satiety, epigastric pain, nausea, vomiting, weight loss, anemia, diarrhea or constipation. This may explain her previous symptoms that were attributed to IBS. The continuous growth of trichobezoars can cause pressure necrosis with resultant mucosal erosions and ulcerations, found most commonly along the lesser curvature and reported in 10% of the patients (6). The diagnosis of a gastric trichobezoar can be confirmed by radiography or endoscopy. Treatment depends on the presentation. Endoscopic retrieval may be attempted for small bezoars. Laparotomy is reserved for bezoars that have perforated (7%), have caused hemorrhage (10%), or are too large or obstructive to be managed non-operatively (2). CORRESPONDENCE TO Mr M. Al-Gailani FRCS Consultant Surgeon Rotherham General Hospital, Moorgate Road, Oakwood, Rotherham, S60 2UD, UK. T: 01709 820000 F: 01709 304180 E: mohamad.al-gailani@rothgen.nhs.uk

Symptomatic Simultaneous Esophageal, Duodenal, Colonic and Anal Involvement by Amyloidosis

Amyloidosis is a rare progressive disease characterized by abnormal protein deposits in one or more organs. Gastrointestinal (GI) amyloidosis is usually asymptomatic, but may present as malabsorption, pseudo-obstruction, and GI bleeding. We report a patient who uncommonly presented with a variety of GI symptoms related to amyloidosis involving esophagus, stomach, duodenum, colon and anus. Case: A 51-year-old man with multiple myeloma (MM) presented with melena and a Hct of 14. Upper endoscopy showed circumferential erythematous, friable mucosa with diffuse oozing in the distal bulb and second portion of duodenum. Hemostasis was achieved by injection of epinephrine. He also had perianal discomfort and bleeding, exam revealed a large verrucous plaque on the left side of the anus extending to perineum. Patient was treated with high doses of PPI. 10 days later the patient returned to hospital complaining of intermittent melena and recent bright red blood per rectum. Repeat endoscopy showed an antral ulcer, inflamed, friable mucosa in duodenum with narrowing, and no active bleeding. Colonoscopy showed erythema, edema and friable mucosa with oozing in the sigmoid colon. All sites including the anal lesion were biopsied. Histopathology demonstrated squamous hyperplasia with dermal amyloid deposits in the anal lesion. The gastric, duodenal and colon biopsies also showed amyloid deposit. Within 2 weeks he developed rapidly progressive dysphagia, inability to maintain oral intake and weight loss. Endoscopy showed no inflammation, ulcer or stricture formation in esophagus. Esophageal biopsy showed amyloid deposit in the mucosa. Speech was normal and he was able to initiate a swallow. The patient underwent a jejunostomy tube placement for feeding. Discussion: This case demonstrates rare symptomatic involvement of almost the entire GI tract with amyloidosis causing upper and lower GI bleeding, dysphagia and a perianal lesion masquerading as squamous cell carcinoma. Esophageal involvement with rapid onset of severe dysphagia requiring J-tube placement is very unusual and represents a motor disorder of the esophagus. Condylomatous cutaneous amyloidosis has been reported, but most of the time well after the diagnosis of amyloidosis has been made. Our case demonstrates the importance of considering GI amyloidosis in the differential diagnosis of a variety of GI symptoms.

Duodenal Behcetʼs Syndrome Successfully Treated with Azathioprine

Behcet's Syndrome is a multisystem inflammatory disorder characterized by recurrent oral and genital ulcers. Ocular, joint, CNS, and GI involvement are all common, but GI lesions are typically resistant to medical therapy. We present a case of deep duodenal ulcers in a 44 year-old female successfully treated with azathioprine. A 44 year-old A.A. female with a history of Behcet's syndrome presented with 3 months of abdominal pain, nausea, and vomiting unresponsive to treatment with rabeprazole and sucralfate. Her symptoms were worse after eating. She denied any hematemasis, melena, hematochezia, diarrhea, or constipation. Medical history showed Behcet's diagnosed as a teenager. Family history showed a father with stomach cancer at 38. There was no history of NSAID use. On exam, multiple aphthous ulcers were seen in the oropharynx. Abdomen was soft and obese with moderate epigastric tenderness. Ophthalmologic, joint, and neurologic exam were all normal. Basic labs and CT of the abdomen were all normal. EGD showed multiple superficial erosions in the antrum and proximal esophagus. Two 1.5×3cm ulcers were seen in the D2 portion of the duodenum. Biopsies showed a non-specific “fibrinopurulent exudate consistent with ulcer.” Antral biopsies were negative for H. pylori. Serum gastrin and a SBFT were normal. Over the next 6 months her symptoms worsened despite the continuation of PPI therapy and the addition of hydroxychloriquine by her rheumatologist. She required large doses of narcotic agents in order to tolerate any food and, despite this, she lost 45 pounds and was forced to go on disability. Subsequent EGDs showed persistence of her large duodenal ulcers and small antral ulcers. Azathioprine 2.5mg/kg was started. Six weeks later, EGD showed resolution of the small antral ulcers and partial resolution of the duodenal ulcers. Subsequently, her symptoms resolved. Four months later, she has gained 20 pounds and no longer requires pain medications. Discussion: GI involvement of Behcet's is variable (2–50% of cases, largely dependent on geographic area of interest). Ileocecal and colonic involvement is most common, and intestinal lesions are usually resistant to medical treatment. There have been two previous case reports of duodenal involvement, each requiring a surgical intervention. A review of 136 Japanese surgical cases showed duodenal involvement in 2 cases. To our knowledge, this is the first report of duodenal Behcet's with successful medical treatment.

Small Bowel Adenocarcinoma Diagnosed by Wireless Capsule Endoscopy

A 67-year old male with a history of melena and iron deficiency anemia, was referred for Wireless Capsule Endoscopy (WCE). 9-months earlier, he noted the onset of increased fatigue and shortness of breath on exertion, along with intermittent episodes of the passage of dark stools. 4-months later he was admitted to the hospital for melena and a drop in hemoglobin. He required 2 units of packed red cells. EGD revealed multiple shallow antral ulcers with dark heme and multiple erosions in the duodenum. Colonoscopy was normal. He was started on Prevacid. 1-month later, he was re-admitted for melena and a drop in hemoglobin, and was transfused 3 units of packed red cells. EGD and Push enteroscopy were performed, which was normal up to 160 cm. He had no abdominal complaints. His appetite was good; weight stable. Additional medical problems included COPD and Chronic Hepatitis B, well compensated Cirrhosis. Medications included Prevacid and Iron. His physical examination was un-remarkable. Stools were guaiac positive. Hemoglobin was 9.5, MCV 63, Serum Iron 15, Ferritin 20. Small bowel series was normal. CT of the abdomen revealed hepatosplenomegaly with suggestion of underlying cirrhosis. WCE revealed a polypoid, ulcerated defect, 6-minutes beyond the ligament of Treitz. There was a marked delay in transit through this segment. Fresh blood was noted in the mid-jejunum. Laparoscopy revealed a 7-cm mass, 30-cm distal to the ligament of Treitz. Wide resection was perfomed, with resection of the adjacent mesentery and lymph nodes. Pathology revealed moderately to well differentiated adenocarcinima, invading through the muscularis propria into the sub-serosa; there was an adjacent tubular adenoma. Metastatic carcinoma was present in 1/5 lymph nodes. CT abdomen did not reveal any distant metastasis. The patient was started on platinum based chemotherapy, and is doing well 4-months post-operative. The diagnosis of small bowel tumors is often difficult due to the rarity of these lesions, and the non-specific presenting symptoms and signs. Most are asymptomatic until the tumor has spread beyond the stage of surgical cure, and contributes to the delay in the diagnosis. WCE is a non-invasive test that provides visualization of the small bowel. Early use of WCE in the evaluation of obscure GI bleeding and iron deficiency anemia may facilitate a more prompt diagnosis of small bowel tumor.

New form of antral and duodenal ulcer in children: plasminogen deficiency

New form of antral and duodenal ulcer in children: plasminogen deficiency

Isolated Vasculitis of the Stomach: A Novel or Rare Disease with a Difficult Differential Diagnosis

In up to 80 % of patients with vasculitis, signs of the disease are also seen in the gastrointestinal tract. However, no cases of exclusively gastric vasculitis have previously been reported. We report here the case of a 45-year-old woman with upper abdominal discomfort (no arthropathy), with gastroscopic and endoscopic ultrasound (EUS) findings that mimicked scirrhous gastric carcinoma. Gastroscopy revealed giant gastric folds and a suspicious antral ulcer (with histological findings suggesting chronic active pangastritis). EUS showed a concentric, thickened gastric wall (8 mm) with "pseudolamellation" and more than five enlarged lymph nodes in the paragastric region (lesser curvature). On the basis of suspected scirrhous gastric carcinoma, the patient underwent a four-fifths gastric resection of the altered parts of the gastric tissue. The postoperative course was uneventful. Histological examination of the specimen revealed severe obliterative panvasculitis of the stomach. During a 22-month follow-up period, no signs or symptoms of systemic primary or secondary vasculitis were found in the patient's medical history, symptoms, laboratory parameters, or imaging. This case shows for the first time that a specific gastric panvasculitis can occur, either as a preliminary stage of the condition or as a distinct manifestation of vasculitis associated with the stomach alone. Gastric resection appears to be indicated in patients with isolated obliterative gastric vasculitis, since it avoids the side effects of long-term immunosuppressive therapy and provides prognostic information that takes account of the differential diagnosis of scirrhous gastric carcinoma.

The value of upper gastro-intestinal fibrescopy.

Abstract In a series of 330 fibrescopies of the upper gastrointestinal tract the most usefull all-round instrument proved to be a long end-viewing panendoscope. The nature of the radilogical errors revaled by endoscopy indicated that the latter is essential before embarking on surgery for antral gastric ulcers, radiographically negative dyspepsia, and further gastric surgery.

A Case of Duodenal Pigmentation in a Patient with Upper Gastrointestinal Bleeding

Case Report: This 67-year-old caucasian female with CAD, CHF, DM type 2, GERD, hypothyroidism, COPD, iron deficiency anemia, and multiple serrated adenomas throughout the colon presented to the ED with dizziness and lightheadedness. She had noticed intermittent black stools over the previous two months since being started on oral iron replacement. However, she described melena and maroon stools for two days prior to admission. She denied chest pain, shortness of breath, nausea, or vomiting. Our patient was found to be orthostatic on examination and lab values revealed acute worsening of known iron deficiency anemia. EGD was performed and revealed gastric AVM's and an antral ulcer (both coagulated using APC). In addition, upon intubation of the duodenum, punctate black pigmentation was identified diffusely throuought the duodenal bulb and second portion of the duodenum. Duodenal biopsies revealed “focal black pigment deposition into the lamina propria of the villi” and a negative iron stain. Further staining, including Fontana Masson with and without bleach, was performed. The pigment disappeared upon bleaching, which reflects that melanin is the probable origin. Discussion: These duodenal findings can possibly be attributed to “Pseudomelanosis duodeni” which is a rare endoscopic entitiy previously reported predominantly in African-American females in the sixth or seventh decade of life. Many reported patients are hypertensive (treated with hydralazine and propranolol in particular), diabetic, have chronic renal disease and have had upper gastrointestinal bleeding. Although exact composition of this pigmentation is unknown, it has been postulated to be melanin, a melanin-like substance, iron, hemosiderin, or lipofuscin. The full clinical significance of this finding has not been elucidated to date. In a patient with the above findings, we propose that he or she be evaluated other systemic entities which may be causative. First, the patient should undergo thorough dermatologic examination to assess for malignant melanoma, which has been described to metastasize to intestinal mucosa. Next, the patient should be evaluated for folic acid deficiency previously described to be associated with melanosis of the duodenum. Also, the patient's full medication history should be obtained (most importantly history of anti-hypertensive therapy).

Selective Serotonin Re-Uptake Inhibitors Aggravate Antral Ulcers Induced by Indomethacin in Rat Stomachs

Background & Aim: Recent clinical studies suggested a risk of gastric adverse reactions on the concomitant use of selective serotonin re-uptake inhibitors (SSRIs) with nonsteroidal anti-inflammatory drugs (NSAIDs). However, little information has been available concerning the adverse effect of SSRIs in the gastrointestinal tract, as well as the underlying mechanism of this action. In the present study, we used indomethacin as a conventional NSAID and investigated the adverse effect of SSRIs on gastric antral and corpus lesions, as well as intestinal lesions induced by indomethacin in rats.

Protective effect of astaxanthin on naproxen-induced gastric antral ulceration in rats

Frequently used for humans as non-steroidal anti-inflammatory drug, naproxen has been known to induce ulcerative gastric lesion. The present study investigated the in vivo protective effect of astaxanthin isolated from Xanthophyllomyces dendrorhous against naproxen-induced gastric antral ulceration in rats. The oral administration of astaxanthin (1, 5, and 25 mg/kg of body weight) showed a significant protection against naproxen (80 mg/kg of body weight)-induced gastric antral ulcer and inhibited elevation of the lipid peroxide level in gastric mucosa. In addition, pretreatment of astaxanthin resulted in a significant increase in the activities of radical scavenging enzymes such as superoxide dismutase, catalase, and glutathione peroxidase. A histologic examination clearly proved that the acute gastric mucosal lesion induced by naproxen nearly disappeared after the pretreatment of astaxanthin. These results suggest that astaxanthin removes the lipid peroxides and free radicals induced by naproxen, and it may offer potential remedy of gastric ulceration.

Selective Serotonin Re-Uptake Inhibitors (SSRIS) Aggravate Antral Ulcers Induced by Indomethacin in Rat Stomachs

Selective Serotonin Re-Uptake Inhibitors (SSRIS) Aggravate Antral Ulcers Induced by Indomethacin in Rat Stomachs

Perforated gastric ulcer--reappraisal of surgical options.

The available operative procedures for perforated gastric ulcer are gastrectomy, ulcer excision and omental patch closure. This study analysed the outcome of these operative options in a single institution. Seventy-two patients (mean age 43 years, 62 males) with perforated gastric ulcers were managed by laparotomy. There were 34 lesser curve (incisural) and 38 antral ulcers. Partial gastrectomy was performed in 27 patients, ulcer excision in 27 and simple patch closure in 18. Two ulcers were malignant. The mortality rate was 18% (26% for gastrectomy, 19% for ulcer excision and 5% for patch closure). Shock on admission (p = 0.006) and Candida (p = 0.020) in the histological specimen were predictive of poor outcome. Hospital stay was similar in the 3 groups. Omental patch closure and ulcer excision are as effective as gastrectomy in the management of perforated gastric ulcer and merit consideration as first-line therapy in technically applicable cases.

Stapled gastroplasty for antral stricture after repair of neonatal gastric rupture: report of a case

The patient was the second of twin girls born at 32 weeks' gestation, weighing 1736 g. Abdominal distention was noted the day after birth, and abdominal x-ray showed free air in the abdomen. An emergent laparotomy with debridement and primary closure were performed for spontaneous gastric rupture. From the age of 8 months, the infant sometimes vomited after meals and was unable to gain weight. She was diagnosed, by upper gastrointestinal series and gastroscopy, with antral stricture with a normal prepyloric area and pylorus. The presence of an antral web, ulcers, or ectopic pancreatic tissue was excluded. There was sufficient distance between the stricture area and the pylorus. Stapled gastroplasty using an Endopath linear cutter stapler and a Proximate linear stapler was performed safely and quickly without injury to the normal pylorus or branches of the vagal nerve at the lesser curvature. The child's postoperative course was uneventful.

Chronic Antral Ulcer Associated With Gastroduodenal Lymphocytic Phlebitis

Enterocolic lymphocytic phlebitis (ELP) is a rare cause of gastrointestinal ischemia. Unlike most vasculitic diseases affecting the gastrointestinal tract, ELP involves only the mural and mesenteric veins, which are surrounded by a lymphocytic and sometimes granulomatous infiltrate. The mesenteric arterial system and the systemic vasculature are characteristically spared. Most patients with ELP present with an acute abdomen that resolves following surgical resection of the involved bowel. ELP has been reported to involve the small bowel, colon, or both, but involvement of the upper gastrointestinal tract has not been previously described. Here we report a case of lymphocytic phlebitis that affected only the stomach and duodenum. The patient, a 68-year-old man, had a nonhealing gastric antral ulcer and underwent hemigastrectomy with vagotomy and Billroth II reconstruction. Both the resected stomach and duodenum showed characteristic lymphocytic and granulomatous infiltrates that involved the submucosal and mural veins, with associated obliteration of vascular lumina; the adjacent arteries were completely spared. The patient developed late postoperative complications including bile reflux gastritis and erosive esophagitis, but he had no recurrence of gastrointestinal ulceration or ischemia over a 2-year follow-up. We hypothesize that there may be more cases of upper gastrointestinal ELP than are diagnosed as such, in part because the diagnosis can be made only on surgical resections specimens.

ENDOSCOPIC ULTRASOUND(EUS) MAY BE SUPERIOR TO SOMATOSTATIN RECEPTOR SCINTIGRAM (OCTREOSCAN) IN THE EVALUATION OF GASTRINOMA

Hypergastrinemia which is commonly associated with either atrophic gastritis or the use of acid-suppressive therapy in the community setting, could also be rarely due to gastrinoma. Elevated levels of gastrin of more than 200-fold should trigger further evaluation for gastrinoma. Such evaluations typically involve octreoscan, computed tomography(CT scan) and magnetic resonance imaging(MRI) in the community setting. In this clinical vignettes, we present a case of a 55 year old gentleman who had a negative CT scan and otreoscan in the evaluation of gastrinoma. Patient had previously presented with weight loss, abdominal pain and elevated serum levels of amylase and lipase suggestive of clinical pancreatitis. His other pertinent symptoms included minimal gastroesophageal reflux symtoms, diarrhea and weakness. Subsequent upper endoscopy showed esophagitis and antral ulcer. Fasting serum gastrin level done was over 2200 pg/ml. Initial work-up to evaluate for gastrinoma included negative abdominal CT scan, MRI and octreoscan. EUS with fine needle aspiration(FNA) showed a peripancreatic mass. Specimen from the FNA done with appropriate immunohistochemical stains revealed gastrinoma. Subsequent exploratory laparotomy and intraoperative ultrasound showed metastatic gastrinoma confirmed by positive tumor cells in the lymph nodes. During the above work-up, treatment with proton pump inhibitor resulted in improvement of his symptoms In this presentation, the use of EUS with FNA enabled the appropriate diagnosis to be made prior to surgery. Further studies may be necessary to confirm the superiority of EUS over octreoscan in the evaluation of gastrinoma

SYMPTOMATIC ESOPHAGEAL DUPLICATION CYST. CASE REPORT AND REVIEW OF LITERATURE

A 34 yo female with a history of gastric ulcers, gerd and asthma presented for follow up egd of her recurrent dyspepsia and recent dysphagia of solids for two months duration. Pt. denied any odynophagia, weight loss, early satiety or fevers. Pt.'s medications included omeprazole and albuterol. Pt. has a family history of colon cancer, a 15 pack year tobacco history, occasional alcohol use and no recent history of travel or risk factors for HIV disease. Physical exam was unremarkable. On EGD, extrinsic compression of the distal esophagus was noted, as well as an irregular Z line and an antral ulcer. CT scan of the chest revealed a 3.5×2.0 cm rounded, smooth walled, soft tissue mass in the anterior border of the distal esophagus. A submucosal mass imaged between 35 and 37 cm was identified on EUS. The mass was localized to the left anterior aspect of the esophageal wall and appeared to involve all layers. There was no adenopathy detected on EUS. Biopsies done at time of EUS were unrevealing for cancer. Pt. underwent Ivor Lewis esophagogastrectomy for definitive diagnosis and treatment. Surgical pathology revealed a large 2 cm, cystic structure that contained mucus and was lined by benign ciliated respiratory epithelium and goblet cells, compatible with a duplication cyst. Multiple smaller cysts were also identified. Benign foci of ectopic salivary gland seromucinous acini and their associated ducts were also present throughout. There was no evidence of malignancy. Esophageal cysts account for 10% of all primary masses of the mediastinum. They can be broadly classified into congenital versus acquired cysts. Esophageal duplication cysts, a subclass of congenital cysts have a prevalence estimated to be 1/8200. Ectopic gastric, pancreatic and salivary gland tissue within these cysts have been descibed. Esophageal cysts usually cause respiratory symptoms in children and are often asymptomatic in adults. Two thirds of esophageal cysts are located in the distal esophagus and about 10% are located in the upper third. The average age of diagnosis for distal lesions is 34 years and the most common presenting symptoms include dysphagia, retrosternal pain and cough. There have been reports of patients presenting with cardiac arrhythmias, intracystic hemorrhage, perforation, infection and transformation into cancer. Regardless of symptoms, surgical resection is the treatment of choice.

GASTRIC SARCOIDOSIS PRESENTING AS UPPER GI BLEEDING

A 61-year-old woman with a history of sarcoidosis, currently in remission, presented with new-onset hematemesis, melena, and lightheadedness. She denied abdominal pain. She had been taking daily aspirin and naproxen for a recent injury. The patient was hemodynamically stable, and abdominal examination was benign. Hemoglobin was 7.6 g/dL. Upper endoscopy revealed multiple gastric ulcers with stigmata of recent bleeding; esophagus and duodenum were normal. Biopsies were taken, and a serology was sent for Helicobacter pylori. Her symptoms resolved after blood transfusion. She was discharged several days later with a hemoglobin of 10.6.g/dL. Discharge medications included pantoprazole 40 mg twice daily and her pre-admission dose of prednisone. The patient returned three days later with recurrent symptoms and three gram decrease in hemoglobin. Repeat upper endoscopy revealed two proximal antral non-bleeding ulcers. Serology from her prior admission was positive for Helicobacter pylori, and oral clarithromycin and amoxicillin were initiated. Biopsy results from her initial endoscopy became available that day and revealed noncaseating granulomas. She was placed on full-dose steroids forpresumed gastric sarcoidosis. Herremaining course was characterized by mild abdominal discomfort, but she had no further signs or symptoms of bleeding. She remained hemodynamically intact with stable hemoglobin. She was discharged several days later with plans for follow-up endoscopy in several weeks. Sarcoidosis is a systemic disease characterized by the presence of noncaseating granulomas, usually affecting intrathoracic structures. Clinically evident gastrointe stinal manifestations of sarcoidosis occur in less that 1% of patients known to have the disease. While sarcoidosis can be seen anywhere in the gastrointestinal tract, gastric disease is most common. Abnormalities seen may include ulceration or gastric lumenal narrowing. Histologic evidence of noncaseating granulomas with evidence of multisystem involvement establishes the disease. This case is unusual in that abdominal pain, apredominant and nearly universal feature seen with gastric sarcoidosis, was absent. Presentation with upper GI bleeding is an infrequent occurrence. Endoscopic findings, however, were consistent with those generally seen in patients with gastric manifestations of sarcoid. This case illustrates the importance of considering the diagnosis of gastric sarcoidosis in patients with pulmonary disease and gastric ulceration.

Yogurt Containing Lactobacillus gasseri OLL2716 Exerts Gastroprotective Action Agaisnt Acute Gastric Lesion and Antral Ulcer in Rats

Yogurt containing Lactobacillus gasseri OLL2716 (LG21 yogurt) is reported to improve Helicobacter pylori-induced gastric mucosal inflammation in clinical studies. However, other beneficial effects of LG21 yogurt have not been clarified. Therefore, we examined whether LG21 yogurt exhibits a gastroprotective action against acute gastric lesion or antral ulcer in rats. Moreover, the mechanism of gastroprotective action was also evaluated. After fasting, acute gastric lesions were induced by 0.6 M HCl. Gastric mucosal folds were stained by oral administration of methyl violet. Antral ulcers were induced by the combined administration of diethyldithiocarbamate and HCl in refed rats after fasting. LG21 yogurt was orally administered before HCl treatment or staining the mucosal folds. LG21 yogurt significantly and dose-dependently inhibited the formation of acute gastric lesions, and this gastroprotective action was attenuated by pretreatment with indomethacin. LG21 yogurt also significantly increased prostaglandin E2 generation in the gastric mucosa. Stained length of gastric mucosal fold was reduced by LG21 yogurt. Antral ulcer formation was also significantly inhibited by LG21 yogurt. From the above results, it was found that the ingestion of LG21 yogurt is useful for the prevention of gastric ulcer. Moreover, endogenous prostaglandin was suggested to be one of the gastroprotective mechanisms of LG21 yogurt.

Hypersensitivity to Nadroparin Calcium

The use of heparin to prevent or treat venous and ethyl abuse, which was stopped 20 years before pulmonary thrombosis, unstable angina and admission. In order to perform right and left side non-ST-elevation myocardial infarction is widely cardiac catheterisation, oral anticoagulants were accepted. Nowadays, for many of these indications switched to nadroparin calcium (Fraxiparine®, Sathe unfractionated heparins (UFH; molecular weight nofi-Synthelabo, Brussels, Belgium)1 7.500U AXa [MW] 3–30 kDa) are largely being replaced by IC (Institut Choay) twice daily. Ten days after startlow-molecular-weight heparins (LMWHs; MW ≤5 ing this preservative-free LMWH he developed a kDa) because of the improved pharmacokinetic and large eczematous plaque (5 × 15cm) at the injection pharmacodynamic properties as well as a better site. There was neither thrombocytopenia nor eosisafety profile of the latter.[1-3] Adverse reactions to nophilia. The lesion subsided within 1 week after heparins include haemorrhages, osteopenia and imstopping the drug and application of a topical cortimune-mediated hypersensitivity reactions, e.g. costeroid. heparin-induced thrombocytopenia without and Investigations were performed in the patient and with (fatal) thrombosis,[4-10] immediate hypersensiin a healthy control who was free of any medication. tivity reactions such as rhinoconjunctivitis,[11] asthA lymphocyte transformation test (LTT) with ma,[12] urticaria, angio-oedema and anaphylaxnadroparin calcium assessed by the incorporation is,[12-25] and delayed cutaneous reactions generally of [methyl-3H] thymidine[36] was strongly positive manifesting as infiltrated, eczematous plaques or with a stimulation index, i.e. counts per minute leukocytoclastic vasculitis (type III Arthus reaction) (cpm) of the nadroparin calcium-stimulated lymat injection sites.[26-35] phocytes divided by the cpm cultured with serumfree medium, of 135 (normal <2). Flow cytometric 1. Case Report analysis of in vitro nadroparin calcium-activated A 47-year-old man with severe heart failure due basophils (BAT)[37] showed a CD63 upregulation to a dilated cardiomyopathy was admitted for carabove spontaneous expression of 63% (normal diac transplantation screening. His medical history <15%). Meanwhile, the patient was re-administered included pacemaker implantation because of a sick nadroparin calcium accidentally, which resulted in sinus syndrome with syncope, depression, osteoan immediate local erythematous eruption of several penia, gastritis, antral ulcers, a small biliary cyst and centimetres and a generalised pruritus and urticaria.

Pseudomembranous Gastritis: A Complication from Aspergillus Infection

Pseudomembranes in the gastrointestinal tract are usually associated with the use of antibiotics, steroids, and severe immunosuppression. Reported cases of this condition have usually been confined to the large and small bowel. We discuss a 41-year-old woman who was transferred to The University of Mississippi Medical Center for severe upper gastrointestinal bleeding after admission to an outside facility following a motor vehicle collision. Upper endoscopy revealed an antral ulcer with fungal hyphae found in the biopsy specimen. Because of her exsanguinating hemorrhage from her gastric pathology a total gastrectomy was performed. Pathological inspection of the stomach revealed a green/brown pseudomembranous gastritis throughout the entire stomach. Aspergillus cultures confirmed the etiologic agent. The patient later fell into multiorgan system failure and died. Autopsy results showed no aspergillus in other organ systems. The current literature suggests that this is the first reported case of isolated pseudomembranous gastric aspergillosis.