Bleeding Duodenal Ulcer Research Articles

Laparoscopic colorectal surgery - why would you not want to have it and, more importantly, not be trained in it? A consecutive series of 500 elective resections with anastomoses

We analysed the outcome of a consecutive series of 500 unselected patients who underwent elective laparoscopic colorectal resection with anastomosis (ELCRA) under the care of a single surgeon. A prospectively collected electronic database of all laparoscopic procedures conducted from April 2001 to September 2008 was analysed. A total of 500 ELCRAs were performed [230 male and 270 female patients; mean age 65.6 years (range 19-93 years; American Society of Anesthesiologists grade I (103), II (246), III (145) and IV (6)]. Of these, 217 patients underwent high anterior resection. A total of 131 total mesorectal excisions (55 covering ileostomies), 152 right/extended right resections and 240 operations were performed by trainees under supervision. The indications for surgery included cancer (340), diverticular disease (96), Crohn's disease (40) and polyps (24). Mean operating time was 115 min (range 35-550 min). There were eight (1.6%) conversions. The mean length of hospital stay was 5.2 days (median 4 days). A total of 93 (18.6%) patients had an inpatient complication, including ileus (22), wound infection (14), anastomotic leakage (12), enterotomy (2), 'off-screen' enterotomy (2), abscess (3), ureteric injury (1), cardiac arrhythmia (12), myocardial infarction (5), pulmonary embolus (4), pneumonia (1), Clostridium difficile (3) and retention of urine (9). There were 20 (4%) readmissions for complications, including ileus (4), urinary retention (3), abscess formation (2) and leakage (2). The 30-day mortality was nine of 500 (1.8%) following anastomotic leakage (3), duodenal enterotomy (1), bleeding duodenal ulcer (1), C. difficile infection (1) and cardiac complications (3). This unselected cohort of patients (the largest single surgeon series in the UK) demonstrates that in trained hands low conversion and complication rates can be consistently achieved.

Hospitalisation of and mortality from bleeding peptic ulcer in Sweden: a nationwide time‐trend analysis

Time-trend analyses of incidence and mortality in bleeding peptic ulcer show divergent results. To conduct a detailed national analysis of hospitalisation of and mortality from bleeding peptic ulcer in Sweden. Data from all hospitalisations at departments with primary responsibility for patients with bleeding ulcer in Sweden, with main diagnosis or co-diagnosis of bleeding ulcer from 1987 to 2005 were retrieved from the Hospital Discharge Register. A validation study was performed due to an uncertainty in diagnostic setting after the introduction of ICD-10 in 1997. Annual hospitalisation rates per 100 000 inhabitants in relation to gender, age and ulcer location were calculated as well as age-standardised 30-day mortality rates. Hospitalisations for bleeding ulcer decreased from 63.9 to 35.3 per 100 000 inhabitants per year during the study period. The decrease was greater among men (men: from 80.4 to 40.9; women: from 47.7 to 29.7) and in younger age groups. Bleeding gastric ulcer decreased in both genders, and bleeding duodenal ulcer decreased most among men, but was stable in a subgroup of elderly women. Median age increased from 70 to 76 years. Standardised 30-day mortality increased from 5.3% to 6.2%. The increased mortality was found in those aged more than 65 years and with duodenal ulcer disease, whereas mortality remained unchanged in those with bleeding gastric ulcer. Hospitalisation rates for bleeding peptic ulcer have markedly decreased in Sweden in all age groups. The 30-day mortality is low compared with other nationwide studies in the western world, but has increased among patients with duodenal ulcer disease.

A Case of Superior Mesenteric Venous Thrombosis Due to Protein C Deficiency in a Patient with Duodenal Ulcer Bleeding

Mesenteric venous thrombosis is a clinically very rare disease, and may cause bowel infarction and gangrene. Difficulty in the diagnosis the disease due to its non-specific symptoms and low prevalence can cause a clinically fatal situation. Mesenteric venous thrombosis may be caused by both congenital and acquired factors, and protein C deficiency, which is a very rare genetic disorder, is one of many causes of mesenteric thrombosis. The authors experienced a case of mesenteric venous thrombosis caused by protein C deficiency in a patient with duodenal ulcer bleeding, so here we report a case together with literature review.

Intramural hematoma of duodenum: An unusual complication after endoscopic therapy for a bleeding peptic ulcer

Intramural hematoma of duodenum (IDH) is a relatively unusual complication associated with endoscopic treatment of bleeding peptic ulcer. This unusual condition is usually seen in children following blunt trauma to the abdomen. We describe here a case of IDH occurring following endoscopic therapy for bleeding duodenal ulcer in an adult patient with end-stage renal disease. The hematomas appeared on the second day of endoscopic intervention, caused transient duodenal obstruction and resolved spontaneously with conservative treatment in a week.

An Experience of Cyberknife Treatment in Patients with Advanced Pancreaticobilliary Malignancy

CyberKnifeTM stereotactic body radiotherapy (SBRT) has been thought as a promising treatment modality for inoperable or recurred pancreaticobiliary malignancies. But, clinical course of CyberKnifeTM treatment have not been established yet, so we report the experience of CyberKnifeTM treatment in 19 patients with recurred or advanced pancreaticobilliary malignancies. Between July 2008 and May 2009, 19 patients (gallbladder cancer 4, common bile duct cancer 5, and pancreatic cancer 10) with recurred (12) and advanced pancreaticobiliary cancer (7) underwent CyberKnifeTM treatment in Soonchunhyang University Hospital. Tumor size was evaluated at 1, 3, 6, 8 and every 3 months after SBRT. The mean age was 60.2 years, and the mean size of target lesions was 28.1±1.30 mm. After CyberKnifeTM treatment, the average size of target lesions was decreased; 2.53±4.18 mm from months 0-1 in 19 patients, 2.47±4.7 mm from months 1-3 in 15 patients, 0.08±5.11 mm from months 3-6 in 12 patients. However, the average size of target lesions was increased 3.67±8.98 mm from months 6-8 in 6 patients. There were 2 cases of massive duodenal ulcer bleeding after CyberKnifeTM treatment, one of them expired due to ulcer bleeding. Also, other minor complications appeared such as 1 case of abdominal pain and 1 case of diarrhea. CyberKnifeTM treatment seems to be effective in local control of pancreaticobiliary cancer, but we experienced serious complications. Further prospective studies will be needed for the proper evaluation of role of CyberknifeTM treatment in patients with advanced pancreaticobiliary malignancies.

Experience of non-vascular complications following endovascular aneurysm repair for abdominal aortic aneurysm

Endovascular aneurysm repair (EVAR) for the treatment of abdominal aortic aneurysm (AAA) is a widely used method, and its decreased invasiveness compared to traditional surgical repair has brought about reduced rates of morbidity and mortality. Several vascular complications related to the procedure have been reported, but non-vascular complications have rarely occurred. We report herein the case of a 78-year-old man who underwent EVAR for AAA and presented with active duodenal ulcer bleeding and acute acalculous cholecystitis as complications after the procedure. We must consider that a wide spectrum of complications may occur following EVAR, and therefore it is important to evaluate the risks of complication and to take the necessary measures to minimize them.

Cephalic Duodenopancreatectomy in the Treatment of a Bleeding Duodenal Ulcer in a Pancreas Recipient: A Case Report

Pancreas transplantation is currently the only known therapy to restore glycemic metabolism in type 1 diabetic patients. Its most prevalent indication is in association with kidney transplantation (simultaneous pancreas and kidney transplantation SPK) for patients with type 1 diabetes mellitus (DM1) and nephropathy, who are under dialysis treatment. Surgical reinterventions, especially those resulting from complications of bladder exocrine pancreatic drainage, are associated with considerable morbidity and mortality. In this report, we present a clinical case of a 31-year-old Caucasian man with DM1 from 12 years of age and hemodialysis for 2 years before undergoing SPK 2 years prior. He then developed massive hematuria owing to a bleeding duodenal graft ulcer. The use of a segmental pancreatic technique with pancreaticocystostomy for exocrine pancreatic drainage allowed the maintenance of the graft and an euglycemic state in the patient, free of exogenous insulin.

Bleeding duodenal ulcer after Roux-en-Y gastric bypass surgery: the value of laparoscopic gastroduodenoscopy.

Roux-en-Y gastric bypass is a common surgical procedure used to treat patients with morbid obesity. One of the rare, but potentially fatal complications of gastric bypass is upper gastrointestinal bleeding, which can pose diagnostic and therapeutic dilemmas. This report describes a 39-year-old male with morbid obesity who underwent a Roux-en-Y gastric bypass. Three months postoperatively, he sustained repeated and severe upper attacks of upper gastrointestinal bleeding. He received multiple blood transfusions, and had repeated upper and lower endoscopies with no diagnostic yield. Finally, he underwent laparoscopic endoscopy which revealed a bleeding duodenal ulcer. About 5 ml of saline with adrenaline was injected, followed by electrocoagulation to seal the overlying cleft and blood vessel. He was also treated with a course of a proton pump inhibitor and given treatment for H pylori eradication with no further attacks of bleeding. Taking in consideration the difficulties in accessing the bypassed stomach endoscopically, laparoscopic endoscopy is a feasible and valuable diagnostic and therapeutic procedure in patients who had gastric bypass.

Is transcatheter arterial embolization a safer alternative than surgery when endoscopic therapy fails in bleeding duodenal ulcer?

Objective. Emergency surgery after unsuccessful endoscopic therapy for bleeding duodenal ulcer has been reported to have a high mortality. Transcatheter arterial embolization (TAE) of the gastroduodenal artery is an alternative strategy when endoscopic therapy fails. This study is a retrospective analysis comparing these two treatment strategies. Material and methods. Patients who underwent TAE (n = 24) or open surgery (n = 50) after unsuccessful endoscopic therapy for bleeding duodenal ulcers at two university hospitals between 2000 and 2007 were compared. Mortality, morbidity, length of hospital stay, age, number of endoscopic interventions and acute physiology and chronic health evaluation (APACHE) II score were evaluated. Results. The groups were comparable concerning gender and length of hospital stay. The mean age (69.6 ± 16.1 versus 61.9 ± 14.1 years; P = 0.043), APACHE II score (17.0 ± 5.1 versus 12.8 ± 5.7; P = 0.004) and number of gastroscopies (P = 0.009) were significantly higher in the embolization group. Five patients (20.8%) died in the embolization group compared to 11 (22%) in the surgery group. However, mortality in high-risk patients (APACHE II score ≥ 16.5) was lower in the TAE group (23.1% versus 50.0%; P = 0.236). Method-related as well as other complications were not significantly different between the two groups. There was, however, a higher re-bleeding rate in the TAE group. Conclusions. TAE of the gastroduodenal artery appears to be a safe alternative when endoscopic therapy for bleeding duodenal ulcer fails, at least in high-risk patients. The role of TAE in low-risk patients with bleeding from duodenal ulcer needs to be defined by means of a prospective controlled trial.

Low-Dose Urokinase in Massive Pulmonary Embolism When Standard Thrombolysis Is Contraindicated

When acute massive pulmonary embolism is life threatening, thrombolysis could be a therapeutic option. However, lysis may be contraindicated once the risk of bleeding is high. We report on two patients who have massive pulmonary emboli complicated by severe hypotension, justifying thrombolytic treatment. Nevertheless, recent surgery in the first patient and a fresh hemorrhagic duodenal ulcer in the second patient precluded thrombolytic treatment at the usual dosage. Therefore, prolonged lysis with low-dose urokinase (1,000 units/kg/h) was initiated. After a few hours, the patients became hemodynamically stable and inotrope/vasopressor doses could be reduced and stopped. No major bleeding was observed. Consequently, prolonged thrombolysis with low-dose urokinase could be an alternative approach to therapy in patients with massive pulmonary emboli when recommended thrombolytic dosages are contraindicated.

Multiple hemorrhagic duodenal ulcers caused by cytomegalovirus infection

Multiple hemorrhagic duodenal ulcers caused by cytomegalovirus infection

Thiamine deficiency as a single cause of life-threatening lactic acidosis in a patient with acute axonal polyneuropathy

SIMI 2009 We present a patient without a history of alcohol abuse with an acute axonal polyneuropathy in combination with a sudden lactic acidosis in whom by exclusion a thiamine deficiency could be established as the only cause of his illness. A 56-year-old man presented with muscle weakness increasing during the prior 4 weeks. He had a history of myocardial infarction, hypertension, duodenal ulcer, a Billroth-1 gastric resection 8 years before, and anemia due to a bleeding duodenal ulcer. One day prior to admission, he was unable to walk due to muscle weakness and numbness in the legs. Initially he had vomiting and diarrhea, but for the prior 2 weeks he was obstipated. He had lost 25 kg bodyweight in the past few months. He used clorazepate, tramadol, venlafaxine, midazolam, lorazepam, enalapril, folic acid, lactulosis and omeprazol, all in unknown dosages. He used primperan to treat the vomiting. No history of consuming an unusual amount of carbohydrates or high calorie malnutrition was reported. His family reported no alcohol consumption at all.

Upper gastrointestinal bleeding related to emphysematous cholecystitis due to Clostridium perfringens

We describe the case of a 46-year-old man admitted for upper gastrointestinal bleeding in the context of cirrhosis. A deep bleeding duodenal ulcer was treated by sclerotherapy. Abdominal pain and fever lead us to perform an abdominal computed tomography, which demonstrated emphysematous cholecystitis. An emergency cholecystectomy was performed and antimicrobial therapy initiated. The patient recovered uneventfully. Links between ulcers and emphysematous cholecystitis are discussed.

Gallbladder Cancer Manifesting as Recurrent Common Bile Duct Stone and Duodenal Ulcer Bleeding

Gallbladder cancer (GBC) is an uncommon disease and is usually asymptomatic. Poor prognosis and high mortality rate have been noted in patients with delayed diagnosis. We report a case of locally advanced GBC with duodenum and colon invasion manifesting as bleeding duodenal ulcer and recurrent common bile duct (CBD) stones. The patient was successfully treated with extended surgery. In patients who have multiple recurrence of CBD stones without common risk factors, concomitant biliary tract malignancy should be included in the differential diagnosis.

Bleeding peptic ulcer – time trends in incidence, treatment and mortality in Sweden

The incidence of peptic ulcer disease was expected to decrease following the introduction of acid inhibitors and Helicobacter pylori eradication. To analyse possible changes in the incidence of bleeding peptic ulcer, treatment and mortality over time. Residents of Malmö hospitalized for bleeding gastric or duodenal ulcer disease during 1987-2004 were identified in hospital databases (n = 1610). The material was divided into 6-year periods to identify changes over time. All patients who had been submitted to emergency surgery (n = 137) were reviewed. The incidence rate for bleeding gastric or duodenal ulcers decreased by one half in males and by one-third in females and emergency operations decreased significantly (9.2%, 7.5% and 5.7% during the three time periods, respectively (P < 0.05). The post-operative mortality tended to decrease (9.7, 2.4 and 3.7%, respectively) and the 30-day mortality rates in the whole material were 1.2%, 3.6% and 3.4% during the different time periods. The incidence of bleeding gastric and duodenal ulcer disease has decreased markedly. Operative treatment has been replaced by endoscopic treatment. The bleeding ulcer-related mortality was less than 4% and has not changed over time.

Endoscopic view of intravascular platinum coil after embolization of bleeding duodenal ulcer: report of two cases

Endoscopic view of intravascular platinum coil after embolization of bleeding duodenal ulcer: report of two cases

Duodenal intramural hematoma and delayed perforation: rare but fatal complication of endoscopic therapy for a bleeding duodenal ulcer

Duodenal intramural hematoma and delayed perforation: rare but fatal complication of endoscopic therapy for a bleeding duodenal ulcer

Intravenous lansoprazole in treating duodenal ulcer bleeding:a multi-center clinical trial

Objective To assess the efficacy and safety of intravenous infusion of lansoprazole in treating duodenal ulcer bleeding.Methods A multi-center,randomized,parallel-controlled,and positive-drug contrast clinical trial was conducted in 216 patients with endoscopic proved duodenal ulcer bleeding.The patients were randomly divided into lansoprazole group(n=110)and control group (n=106).Patients in lansoprazole group were intravenously received lansoprazole(Allwell)of 30 mg twice daily for 5 days,while those in control group were intravenously received omeprazole sodium (Losee)of 40 mg twice daily for 5 days.Results There were 212 cases qualified for analysis of efficacy and safety.The effective rate and response rate were 73.39 0A and 95.41%in lansoprazole group respectively,while they were 81.55%and 95.15%in control group,respectively(P＞0.05).Haemostatic time and haemostatic rate were(31.90±18.58)h and 98.17%in lansoprazole group respectively,while they were(28.00±18.31)h and 99.03%in control group,respectively(P＞0.05).The major adverse events were leucopenia,slight elevated transaminase and rach(P＞0.05).Conclusion Intravenous lansoprazole is a safe and effective drug for treatment of duodenal ulcer bleeding. Key words: Duodenal ulcer; Bleeding; Lansoprazole

Late onset hypogonadism: an alternate cause for night sweats in the haematology clinic

Late onset hypogonadism: an alternate cause for night sweats in the haematology clinic

Is There a Subgroup of Patients with Forrest IB (Oozing) Peptic Ulcer Bleeding At Increased Risk of Re-Bleeding?

Background: A dichotomy exists among peptic ulcer bleeds (PUB) of oozing appearance (Forrest class Ib), in that a clot or visible vessel is apparent in some cases. Whether such stigmata increase the risk of re-bleeding remains unknown. As part of a recent study of acid-suppressive therapy after successful endoscopic therapy for PUB with high-risk stigmata [1], we report a re-assessment by the study Endpoint Committee (EpC) of re-bleeding among patients (pts) with Forrest Ib (oozing) ulcers to determine whether a subgroup indeed exists that exhibits increased risk of re-bleeding. Methods: In this double-blind, randomized clinical trial (NCT00251979), intravenous esomeprazole (80mg infusion over 30min, then 8mg/h for 71.5h) was compared with matching placebo for prevention of re-bleeding after successful endoscopic hemostasis of PUB. All patients had a single bleeding gastric or duodenal ulcer (≥5 mm diameter, treated endoscopically). Post-infusion, both groups received open-label oral esomeprazole 40mg qd for 27d. As part of the present analysis, the rate of clinically significant re-bleeding (large volume hematemesis, presence of 2 of 3 possible clinical signs of re-bleeding [recurrent melena, drop in Hct, unstable BP or pulse]) within 30d was evaluated for those with Forrest Ib ulcers before endoscopic hemostasis. Baseline ulcer photo documentation was independently re-evaluated by the EpC (DMJ and RS) and Forrest Ib ulcers were further subclassified according to the presence/absence of a clot or visible vessel. Results: A total of 273 pts with Forrest Ib ulcers and available photo documentation were evaluated and reclassified. There was agreement among the EpC on the presence of a clot or visible vessel, respectively, in 90 pts (33.0%). In such pts, the re-bleeding rate was 10.0% (9/90) vs 0% (0/29) in those where the EpC agreed on the absence of a clot or visible vessel (p=.09). In the remaining cases, where the EpC did not agree on the presence/absence of a clot or visible vessel, the re-bleeding rate was 6.5% (10/154). Hence, the re-bleeding rate in the Forrest Ib subgroup with a clot or visible vessel was similar to that of the overall study population (10.7%). Conclusions: Among PUB pts with Forrest Ib (oozing) ulcers, a subgroup with both a clot or a visible vessel and oozing appears to have an increased risk of re-bleeding vs those with only oozing and no additional stigmata. Modification of the Forrest Ib classification may therefore increase its precision in identifying PUB pts with a higher risk of re-bleeding.Supported by AstraZeneca R&D, Mölndal, Sweden[1] Sung JJY, et al. GUT 2008;57 Suppl. II: A70