Complicated Ulcer Disease Research Articles

Impact of the coronavirus disease 2019 pandemic on the management of acute peptic ulcer perforation: to be reconsidered(?).

Peptic ulcer perforation presents the most serious complication of ulcer disease with mortality that varies significantly depending on the age and conditions. The coronavirus disease 2019 pandemic was effective worldwide in 2020 and continues to date. The aim of this study was to investigate the initial clinical parameters and short-term outcomes of patients with acute peptic ulcer perforation before and during the coronavirus disease 2019 pandemic. A retrospective cohort study was conducted in the Department of Surgery, University Hospital Ostrava, Czech Republic. The patients undergoing surgical modality of a simple suture of peptic ulcer perforation with/without omentoplasty in the post-coronavirus disease 2019 (January 1, 2020 to December 31, 2021) and the pre-coronavirus disease 2019 (January 1, 2018 to December 31, 2019) had been incorporated in this study. This study included a total of 46 cases (26 in the pre-coronavirus disease 2019, 20 in the post-coronavirus disease 2019). The age, body mass index, Boey score, duration of symptoms, surgery time, and length of hospital stay were comparable in both study subgroups. During the coronavirus disease 2019 pandemic, patients were admitted with a statistically significantly lower degree of perioperative risk according to the American Society of Anesthesiologists classification (p=0.013). Notably, 30-day postoperative morbidity was significantly higher in pre-coronavirus disease 2019 (73.1 vs. 55.0%, p=0.038). The mortality rate in the laparoscopic group was 13.6%, in the laparotomy group 41.4%, and the mortality rate was higher in pre-coronavirus disease 2019 than in post-coronavirus disease 2019 (34.6 vs. 20.0%, p=0.166). In fact, the coronavirus disease 2019 pandemic had not significantly influenced therapeutic management and short-term outcomes of patients undergoing acute surgical repair of peptic ulcer perforation.

Chemoprevention of Barrett's Esophagus and Esophageal Adenocarcinoma.

Barrett's esophagus is common in Western countries, but progression to esophageal adenocarcinoma is uncommon. Chemoprevention therefore needs to consider whether benefits outweigh risks given an otherwise healthy population. This will depend on the particular population at risk and the relative safety of a potential preventive agent. Most evidence regarding the potential benefit of chemoprevention of Barrett's esophagus and prevention of progression to esophageal adenocarcinoma is based on observational studies such as case-control and cohort studies. Given the potential benefits and relatively low risks, patients with BE should receive once-daily PPI therapy, but routine use of twice-daily PPI is not recommended unless necessitated by poor control of reflux symptoms or esophagitis. Recent data suggest that the inverse associations between aspirin/NSAID use and esophageal adenocarcinoma may be the result of reducing neoplastic progression (from metaplasia to dysplasia and carcinoma) rather than initiation of Barrett's esophagus. While substantial associative data suggest a potential benefit of aspirin and nonaspirin NSAIDs in reducing the risk of progression of Barrett's esophagus, the low risk of progression and the potential risks (gastrointestinal bleeding, complicated ulcer disease, hemorrhagic stroke) do not warrant routine use, unless dictated by cardiovascular risk. Chemoprevention after mucosal ablation in those at highest risk of post-ablation recurrence (dysplastic Barrett's) is currently under investigation.

ИССЛЕДОВАНИЕ КАЧЕСТВА ЖИЗНИ ПАЦИЕНТОВ – ВАЖНЫЙ ИНСТРУМЕНТ ДЛЯ ОЦЕНКИ ЭФФЕКТИВНОСТИ МЕТОДОВ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ОСЛОЖНЁННОЙ ЯЗВЕННОЙ БОЛЕЗНИ

Objective: Complicated peptic ulcer disease provides a serious medico-social problem. The article presents literature data dedicated to the study of the quality of life, as a result of conservative and surgical treatment of patients with various complications of the ulcerative disease. Given a brief characteristic of the concept of quality of life, modern approaches to the definition of this indicator presented a list of questionnaires used in gastroenterology. The method of quality of life research allows to characterize the current functional state the patient to assess the effectiveness of surgical and medical treatment and may serve as additional criteria in choosing a method of surgical treatment of complicated forms of ulcer disease. Assessment of the dynamics of quality of life indicators allows improving the system of rehabilitation assistance. Thus, the quality of life should be considered as an important independent measure of the disease and the efficacy of surgical treatment of complicated ulcer disease. Keywords: Peptic ulcer disease, complications, surgical treatment, quality of life.

Trend in Gastric Outlet Obstruction at Patients Attending Tribhuvan University Teaching Hospital, Kathmandu, Nepal

IntroductionGastric outlet obstruction (GOO) involves obstruc_on in the antro-pyloric region or bulb of duodenum. Malignancy is common cause of GOO in adults but many patients with GOO have benign causes. Despite the improvement in medical management, about 5% patients with complicated duodenal ulcer disease and 1%-2% with complicated gastric ulcer disease respectively develop this problem.ObjectiveThe purpose of this study was to find the etiologies of GOO, their management options and outcome in Tribhuvan University Teaching Hospital.MethodologyIn this retrospective study, the records of 44 patients admited with diagnosis of GOO from September 2007 to August 2010 in the Department of Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal were retrieved. Patients' demography, etiologies of GOO, treatment given and their outcome were analysed.ResultsThirty two patients (73%) were male and 12 (27%) were female with M:F ratio of 2.7:1. The mean age of patients was 57.40 years and duration of symptoms 2.68 months. Carcinoma of stomach, 28 cases (64%) was most common ecology of GOO followed by PUD, 9 (21%), duodenal malignancy,3 (7%), corrosive stricture, 2 (5%), advanced gallbladder carcinoma, 1 (2%) and chronic pancreatis, 1 (2%). Seventeen (39%) patients were treated by gastrojejunostomy, 14 (32%) by subtotal gastrectomy and gastrojejunostomy, 5 (11%) by truncal vagotomy and gastrojejunostomy, 4 (9%) by medical management, 2 (4.5%) by feeding jejunostomy, and 2 (4.5%) were discharged on request. Complications occurred in 7 (16%) patients and mortality in 1 (2%). Twenty three (52%) patients were candidates for chemotherapy either in an adjuvant or palliative seting.ConclusionGastric malignancy was the most common cause of gastric outlet obstruction. Most of the patients in our setup presented with advanced disease and were candidates of palliative treatment only. Birat Journal of Health Sciences Vol.2/No.1/Issue 2/ Jan - April 2017, Page: 219-221

World Gastroenterology Organisation Global Guidelines: GERD Global Perspective on Gastroesophageal Reflux Disease.

PROBIOTICS—THE CONCEPTHistory and DefinitionsA century ago, Elie Metchnikoff (a Russian scientist, Nobel laureate, and professor at the Pasteur Institute in Paris) postulated that lactic acid bacteria (LAB) offered health benefits capable of promoting longevity. He suggested that “intestinal autoint

A systematic approach for the diagnosis and treatment of idiopathic peptic ulcers.

An idiopathic peptic ulcer is defined as an ulcer with unknown cause or an ulcer that appears to arise spontaneously. The first step in treatment is to exclude common possible causes, including Helicobacter pylori infection, infection with other pathogens, ulcerogenic drugs, and uncommon diseases with upper gastrointestinal manifestations. When all known causes are excluded, a diagnosis of idiopathic peptic ulcer can be made. A patient whose peptic ulcer is idiopathic may have a higher risk for complicated ulcer disease, a poorer response to gastric acid suppressants, and a higher recurrence rate after treatment. Risk factors associated with this disease may include genetic predisposition, older age, chronic mesenteric ischemia, smoking, concomitant diseases, a higher American Society of Anesthesiologists score, and higher stress. Therefore, the diagnosis and management of emerging disease should systematically explore all known causes and treat underlying disease, while including regular endoscopic surveillance to confirm ulcer healing and the use of proton-pump inhibitors on a case-by-case basis.

Damage control surgery for abdominal emergencies

Damage control surgery is a management sequence initiated to reduce the risk of death in severely injured patients presenting with physiological derangement. Damage control principles have emerged as an approach in non-trauma abdominal emergencies in order to reduce mortality compared with primary definitive surgery. A PubMed/MEDLINE literature review was conducted of data available over the past decade (up to August 2013) to gain information on current understanding of damage control surgery for abdominal surgical emergencies. Future directions for research are discussed. Damage control surgery facilitates a strategy for life-saving intervention for critically ill patients by abbreviated laparotomy with subsequent reoperation for delayed definitive repair after physiological resuscitation. The six-phase strategy (including damage control resuscitation in phase 0) is similar to that for severely injured patients, although non-trauma indications include shock from uncontrolled haemorrhage or sepsis. Minimal evidence exists to validate the benefit of damage control surgery in general surgical abdominal emergencies. The collective published experience over the past decade is limited to 16 studies including a total of 455 (range 3-99) patients, of which the majority are retrospective case series. However, the concept has widespread acceptance by emergency surgeons, and appears a logical extension from pathophysiological principles in trauma to haemorrhage and sepsis. The benefits of this strategy depend on careful patient selection. Damage control surgery has been performed for a wide range of indications, but most frequently for uncontrolled bleeding during elective surgery, haemorrhage from complicated gastroduodenal ulcer disease, generalized peritonitis, acute mesenteric ischaemia and other sources of intra-abdominal sepsis. Damage control surgery is employed in a wide range of abdominal emergencies and is an increasingly recognized life-saving tactic in emergency surgery performed on physiologically deranged patients.

OP0119 Great progress but much more needed: Hospitalizations due to complicated gastric and duodenal ulcers in the US (1990-2009)

BackgroundGastrointestinal bleeding, perforation, and obstruction of gastric (GU) and duodenal ulcers (DU) (collectively Peptic Ulcer Disease, PUD) are significant causes of hospitalizations and mortality in the US.ObjectivesTo examine hospitalizations due...

Helicobacter pylori and Nonmalignant Diseases

The incidence of peptic ulcer disease has declined over the last few decades, particularly in Western populations, most likely as a result of the decrease in Helicobacter pylori infection and the widespread use of proton-pump inhibitors (PPI) in patients with dyspepsia. The hospital admission rate for uncomplicated duodenal and gastric ulcers has significantly decreased worldwide. In contrast, admissions for complicated ulcer disease, such as bleeding peptic ulcers and perforation, remained relatively stable. Prophylactic H. pylori eradication was found to be associated with a reduced risk of both gastric and duodenal ulcers and their complications, including bleeding in chronic users of nonsteroidal anti-inflammatory drugs. The recent Helicobacter Eradication Relief of Dyspeptic Symptoms trial presented important data relating to symptoms and quality of life of H. pylori-positive patients with functional dyspepsia (FD) and also demonstrated significant benefits from eradication compared with the control group. The new Asian consensus report on FD recommended that dyspepsia accompanied by H. pylori infection should be considered a separate disease entity from FD and that H. pylori infection should be eradicated before diagnosing FD. The association of H. pylori with gastroesophageal reflux disease (GERD) is still controversial. Treatment for H. pylori does not seem to increase GERD symptoms or reflux esophagitis. However, documented eradication of H. pylori appears to significantly improve GERD symptoms. Additional long-term intervention studies are needed to provide more information on which to base clinical decisions.

Apport de la laparoscopie dans le traitement de l’ulcère duodénal perforé : à propos de 20 cas

perforation of duodenal peptic ulcer is a serious complication of ulcer disease. Aim: The purpose of our work is to study its surgical treatment by laparoscopy in our context of developing countries, and to assess the results in terms of mortality and morbidity. Patients and methods: twenty patients were enrolled in a prospective study realized in the Surgical Emergencies Unit of General Surgery Department of Aristide Le Dantec Hospital in Dakar, from October 2006 to July 2008. The procedure was first always laparoscopic. Surgical treatment always carried a suture of the ulcer, an epiplooplasty and a peritoneal toilet. All patients received a cure for the eradication of Helicobacter pylori. Results: There were 19 males and 1 female with an average age of 34.5 years (extremes: 20-63 years). The average time between the onset of symptoms and surgery was 32 hours (extremes: 6 and 72 hours). Exploration had found a perforation of a peptic ulcer of the duodenum bulb front in 18 patients. Conversion was performed in 2 cases (10%). The average duration of the intervention was 45 minutes (extremes: 22 and 110 minutes). One patient died after post operative peritonitis. Two cases of morbidity (10%) were found. There were 2 cases of fever untagged. The average length of hospitalization was 5 days (extremes: 4-7 days). With an average decrease of 2 years, the anatomical and functional results are good. Conclusion: Laparoscopic treatment of duodenal peptic ulcer perforation is a safe alternative in our developing countries with a low rate of morbidity and mortality

Presentation, response to lansoprazole therapy, and outcome of Zollinger–Ellison syndrome-like gastric acid hypersecretors

Objective. To evaluate the clinical characteristics, response to treatment and outcome of Zollinger–Ellison syndrome (ZES)-like gastric acid hypersecretors. Methods. Over a 20-year period, patients with gastric acid hypersecretion in the absence of ZES were enrolled in an open label prospective trial evaluating the efficacy of lansoprazole. Following baseline evaluations, patients were treated with escalating doses of lansoprazole based on the results of gastric acid analysis. Following stabilization, patients were followed on a 6 monthly basis with interval history, physical examination, endoscopy with gastric biopsies, gastric acid analysis, and laboratory studies. Results. The study group represented 21 patients (median age 47 years, 86% male, 91% Caucasian). Historically, complicated ulcer disease was frequent and symptoms had been present for a median of 10 years before study entry. All patients responded to lansoprazole (median dose 90 mg/day) with excellent control of gastric acid hypersecretion. Mucosal relapse was infrequent and no major complications developed while on therapy. Conclusions. ZES-like gastric acid hypersecretion presents similarly to the classic syndrome. Lansoprazole titrated to gastric acid output is effective in healing mucosal disease and preventing relapse.

Prospective Evaluation of Quality of Life in Patients with Zollinger–Ellison Syndrome

Zollinger-Ellison syndrome (ZES) is associated with complicated ulcer disease of the upper gastrointestinal tract. While management of ZES has dramatically improved with proton pump inhibitor therapy, quality of life in medically treated patients has not been evaluated. Over a 3-year period, 52 patients with ZES were prospectively evaluated at 6-month intervals with upper endoscopy and gastric acid analysis to evaluate the efficacy of current drug therapy and completion of SF36v2 forms. At each 6-month visit, patients' medication and problem lists were reviewed, comorbidities assessed, and any gastrointestinal symptoms recorded. Co-morbidity was represented as a simple illness count for the main analysis. The chronic disease score and the Charlson index were used for sensitivity analyses. The unadjusted norm-based estimate of mental component score (MCS) for 52 patients with ZES (mean age 58, 65% male) was 49.8 (95% CI 46.4, 53.1). The unadjusted estimate of the physical component score (PCS) was 42.3 (95% CI 38.9, 45.7). As the number of illnesses or number of medications increased, there was a monotonic decrease in PCS scores. With multivariable adjustment, the coefficient for number of medications became non-significant. An increase in each of the co-morbidity indexes was associated with a decrease in PCS. Results did not vary by representation of co-morbidity. MCS was not significantly different from the general population. Patients with medically managed ZES have norm-based estimates of the mental component scores as measured by the SF-36v2 that approximate normal values, while the physical component scores were decreased with this reduction largely explained by co-morbid illness.

Rokcall score versus forrest classification in endoscopic management of bleeding peptic ulcer

Acute upper gastrointestinal bleeding (UGIB) remains an important emergency situation. In the last two decades, major developments took place influencing incidence, etiology and outcome of patients with acute UGIB. Peptic ulcer bleeding is the most significant complication of ulcer disease being responsible for 50% of all cases mortality. Aim of the study: To compare between endoscopic clip application versus argon plasma coagulation in management of bleeding peptic ulcer (BPU). Patients and Methods: Sixty patients suffering from acute UGIB were randomly divided into two groups: group I included 30 patients treated with endoscopic clip application and Group II included 30 patients subjected to endoscopic APC. All patients were classified according to Forrest classification and the clinical Rockall score. Results: There were significant differences between the two groups as regard Forrest classification (P 0.05). Re bleeding was significant with higher Rockall score in group I (P 0.05). Conclusion: Endoscopic application of hemoclips have a less re bleeding rate than Argon plasma coagulation for treatment of bleeding peptic ulcer, although this was statistically insignificant, meanwhile APC is still less cost and easy. Clinical and endoscopic assessment (through Rokcall score and Forrest classification) could help in making best choice for endoscopic management.

Surgical management of complicated ulcer disease

The advent of excellent acid-suppressing medications and the not-so-recent realization of the importance of Helicobacter pylori have markedly altered the physician's management of ulcer-related problems. Although the investigation of acid-peptic disorders helped to launch the modern understanding of abdominal surgery, the majority of operative interventions are now aimed at managing emergent problems that arise from ulcers. There are a waning number of surgeons with extensive experience in the operations that will be described in this report. The global management of patients who suffer from ulcer-related problems will require close cooperation among and between specialties, as well as clear understanding of our respective capabilities and limitations.

Asymptomatic duodenal ulcers occurring during maintenance treatment with ranitidine

Fifty-seven patients who developed asymptomatic recurrence of duodenal ulceration during maintenance treatment with ranitidine were followed up to assess the risk of developing symptoms or complications of ulcer disease. The risk of development of symptomatic ulcer recurrence was 4% in the first year of follow-up during continuous maintenance treatment, irrespective of whether or not the asymptomatic ulcer had been actively treated (by doubling the dose of ranitidine used for maintenance therapy). The asymptomatic duodenal ulceration during maintenance treatment did not predispose to complications such as haemorrhage or perforation. It seems, therefore, that patients receiving maintenance treatment for duodenal ulceration do not require endoscopic re-examination unless symptoms have recurred, because the asymptomatic recurrences of duodenal ulceration occurring during maintenance treatment are clinically benign, usually heal spontaneously if maintenance treatment is continued, and do not require active medical intervention.

P37: Complicated ulcer disease following RYGBP

P37: Complicated ulcer disease following RYGBP

Ulcers and Gastritis

Significant advances continue to be made in the area of gastritis and ulcer disease. Studies to identify the most appropriate use of capsule endoscopy have now confirmed that it is superior to other methods for identifying small-bowel mucosal pathology and sites of obscure gastrointestinal bleeding. It has increasingly been recognized that the complications of ulcer disease are secondary to the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and to interactions between NSAIDs and Helicobacter pylori. Effective prophylaxis for NSAID in H. pylori-negative individuals continues to be a challenge, as it has become clear that conclusions from studies focusing on endoscopic ulcers in patients whose H. pylori status was unknown provided a false sense of security. The concept of multifocal atrophic gastritis has been challenged. The precursor lesion to gastric cancer now appears to be a sheet of pseudopyloric metaplasia advancing into the gastric body with islands of intestinal metaplasia embedded within it. Multifactorial models such as those proposed for understanding periodontal disease, including the organism, environmental factors, and host factors, appear particularly applicable to understanding the pathogenesis of H. pylori-associated gastric cancer.

Comparing 2 Revolutions

Purpose: H. pylori eradication has revolutionized the management of peptic ulcer disease. A second major revolution occurred when COX-2 selective inhibitors were introduced in 1999 with a GI safety advantage. We assessed the impact of COX-2 selective inhibitor use by examining trends of hospitalizations due to complicated gastric (GU) and duodenal ulcers (DU) over a period of 11 years and relating them to the total prescriptions of NSAIDs, H. pylori eradication, and PPI use. Methods: The Nationwide Inpatient Sample (NIS) is a stratified random sample of US community hospitals with information on all inpatient care regardless of insurance status. We studied all inpatient hospitalizations in NIS from 1990 to 2001 with a primary diagnosis of complicated GU, DU, or peptic ulcer disease (PUD) with hemorrhage, perforation, and/or obstruction, and analyzed them as a proportion of total NSAID prescriptions (data from IMS) during the same time. Results: From 1990–2001 there were 423,558,416 hospitalizations in 3.2 billion person-years of observation. Of these, 1,865,687 hospitalizations (0.44% of total) were for a primary diagnosis of a complicated GU, DU, or PUD (58.4 per 100,000 US population). During this time, there were 982.2 million NSAID prescriptions in the US. Annual NSAID prescriptions increased from 67.6 million (1990) to 112.8 million (2001), with the largest increase from 1998 (79.2 million) to 2001 (112.8 million). PPI prescriptions rose from 3.9 million in 1992 to 73.6 million in 2001. Complicated GU, DU, or PUD hospitalizations declined from 163,173 in 1990 to 139,597 in 2001. The rate of GU, DU or PUD hospitalizations per 100,000 NSAID prescriptions declined by almost 50%, from 241.5 in 1990 to 123.8 in 2001 (P < 0.0001). While such hospitalizations declined steadily from 1992 (perhaps reflecting PPI use), there were 2 periods of additional sharp declines: the first (10.8%, 1995) following the NIH consensus conference recommending H. pylori eradication, and the second (22.4%, 1999) after the introduction of COX-2 selective inhibitors. Conclusions: These data strongly suggest that the introduction of H. pylori eradication therapy, increasing use of PPIs and the introduction of COX-2 selective inhibitors account for the trend toward fewer hospitalizations for complicated ulcer disease in the US. The impact of COX-2 selective agents on ulcer hospitalizations and mortality is twice as much as that of H. pylori eradication.

Gastrointestinal hemorrhage due to complicated gastroduodenal ulcer disease in liver transplant patients taking sirolimus

Sirolimus is emerging as a popular immunosuppressive agent for patients undergoing solid organ and pancreatic cell transplantation. Here, we report the clinical courses of three patients receiving sirolimus who developed aggressive gastroduodenal ulcer disease. One patient died from massive gastrointestinal bleeding, and ulcers in the other two patients healed only after discontinuation of sirolimus. We propose that the mechanism underlying this severe ulcer diathesis, and poor ulcer healing, was linked to the well-known inhibitory effects of sirolimus on wound healing. We propose that sirolimus should be used carefully (or even withheld) in patients with known or previous ulcer disease, and further that it should be used prudently and/or in conjunction with aggressive prophylaxis therapy in those at risk for ulcer disease.

Management of Complicated Peptic Ulcer Disease

Our understanding of the pathophysiological features of peptic ulcer disease has rapidly evolved during the last century. Early understanding of gastric physiologic characteristics led to logical and time-tested surgical procedures aimed at acid reduction and a lowering of ulcer recurrence rates. A dramatic shift in treatment occurred with the recognition and growing knowledge of Helicobacter pylori (HP). Where once surgery dominated therapy for ulcer diathesis, medical therapy has now superseded. Just as gastric resection seemed radical to Dr Mayo, thus was medical treatment of peptic ulcer disease similarly approached with skepticism. What was the balance of medical and surgical management of peptic ulcer disease as we entered the 21st century? Complications of peptic ulcer disease requiring operative intervention have remained important. However, the absolute number of procedures performed has significantly diminished in recent years. 1 The reason for the decrease in surgical intervention, both emergent and elective, is multifactorial. Improvements in therapeutic endoscopy, the introduction of effective antacid therapy, and the recognition and treatment of HP infection have all greatly contributed to the successful nonoperative treatment of patients with peptic ulcer disease. 2-5 With respect to complicated ulcer disease, treatment and eradication of HP infection have arguably led to a shift from treating patients operatively to treating them nonoperatively. This changing management scheme has occurred despite a relative paucity of data regarding the incidence and contribution of HP infection to the etiology of complicated peptic ulcers. Indeed, reports in the literature regarding the incidence of HP infection in a surgical cohort have been sparse. From a surgeon's perspective, data relative to HP infection and the classic indications for surgery-perforation, bleeding, and gastric outlet obstruction (GOO)- have until recently been largely inferential based on treatment of those with uncomplicated peptic ulcers. Deviation from traditional surgical management might prove detrimental should other nonoperative modalities be used. The purpose of this discussion is to review the known pathophysiological features of peptic ulcer disease with a focus on those complications encountered by the surgeon.