Intractable Duodenal Ulcer Research Articles

A Case of Intractable Duodenal Ulcer Complicated by Stenosis in a 25-year-old Woman

A Case of Intractable Duodenal Ulcer Complicated by Stenosis in a 25-year-old Woman

Successful treatment of intractable duodenal ulcer due to pancreatic arteriovenous malformation with transcatheter arterial embolization

Successful treatment of intractable duodenal ulcer due to pancreatic arteriovenous malformation with transcatheter arterial embolization

Insertion of a biliary stent from the stomach. case report of ectopic opening of the common bile duct in the pyloric canal

Introduction: The major papilla of Vater is usually located in the descending part of the duodenum on the posterior medial wall. Occasionally it may be found in other sites, including the stomach, the pyloric canal, the duodenal bulb and the third or the fourth portion of the duodenum. Most commonly, the distance between the pyloric sphincter and the papilla of Vater is longer than 5cm. Case: A 68 old male was admitted to our hospital because of painful obstructive jaundice. The patient had relapsing ulcer disease for more than 40 years and some episodes of spontaneously disappearing obstructive jaundice, but unsuccessful ERCP at one occasion. Abdominal US, CT and MRCP revealed extremly dilated (up to 30mm) common bile duct, stones in the gallbladder and the common bile duct, and a large abscess in the antral wall of the stomach. ERCP was performed. No papilla-like structure was found in the usual position, but the separate opening of the common bile duct and pancreatic duct were found in the pyloric canal. The common bile duct stones were removed after balloon dilation of the biliary opening and a 7-French double pigtail stent was inserted into the biliary tree by duodenoscope positioned in the antral region of the stomach. After desicterisation of the patient elective surgery was performed containing the followings procedures: cholecystectomy, biliodigestive anastomosis and evacuation of the subphrenic abscess. The patient recovered uneventfully. Discussion: Anomalous biliary opening outside the usual localisation can make ERCP difficult. Moreover, the procedure cannot be performed, if the anomy in not notified at all. In our case, the anomalous outflow of the bile and pancreatic juice could be associated with recurrent, intractable duodenal ulcer and recurrent biliary obstruction.

EUS diagnosis of ectopic opening of the common bile duct in the duodenal bulb: A case report

Among the various congenital anomalies of the biliary system, an ectopic opening of the common bile duct (CBD) in the duodenal bulb is extremely rare. ERCP is essential for diagnosing the anomaly. A 55-year-old male was admitted to hospital for severe right upper quadrant abdominal pain, followed by fever, chills, elevated body temperature and mild icterus. The diagnosis of ectopic opening of CBD in the duodenal bulb was established on endoscopic ultrasonography (EUS), which clearly demonstrated dilated CBD, with multiple stones and air in the lumen, draining into the bulb. A normal pancreatic duct, which did not drain into the bulb, was also observed. This finding was confirmed on ERCP and surgery. As far as we know, this is the first case of this anomaly diagnosed by EUS. Ectopic opening of the CBD in the duodenal bulb is not an incidental finding, but a pathologic condition which can be associated with clinical entities such as recurrent or intractable duodenal ulcer, recurrent biliary pain, choledocholithiasis or acute cholangitis. Endoscopic ultrasonography features allow preoperative diagnosis of this anomaly and can replace ERCP as a first diagnostic tool in such clinical circumstances. Embryology of the anomalies of the extrahepatic biliary tree has been also reviewed.

胆嚢十二指腸瘻を合併した難治性十二指腸潰瘍に対し腹腔鏡下手術を行った1例

胆嚢十二指腸瘻を合併した難治性十二指腸潰瘍に対し腹腔鏡下手術を行った1例

Ectopic opening of the common bile duct in the duodenal bulb: clinical implications.

An ectopic opening of the common bile duct in the duodenal bulb is extremely rare, and the clinical significance of this anomaly has not been clarified. This study analyzed the clinical implications and cholangiographic findings of this anomaly. A total of 18 patients (15 men, 3 women; median age, 51 years) with an ectopic opening of the common bile duct in the duodenal bulb were studied. Medical records, endoscopic findings, and cholangiographic and other radiographic findings were reviewed. All 18 patients had biliary pain; 7 had fever and chills. Fifteen (83%) had diffuse dilatation of the extrahepatic bile ducts with or without intrahepatic bile duct dilation. Associated bile duct stones were found in 10 (56%) patients. The papilla in the bulb had an orifice stained with bile at endoscopy, which was associated with duodenal ulcer disease found in 13 (72%) patients. The distal end of the common bile duct was tapered and narrowed and had a hook shape in all patients. An ectopic opening of the common bile duct in the duodenal bulb may be associated with clinical entities such as recurrent or intractable duodenal ulcer, choledocholithiasis, or acute cholangitis. Although these openings are rare, knowledge of the endoscopic and radiographic findings of an ectopic opening of the common bile duct in the duodenal bulb may help to clarify the cause of chronic recurrent duodenal ulcer disease in some patients and prevent damage to the bile duct during surgery.

A new surgical strategy for cirrhotic patients with hepatocellular carcinoma and hypersplenism. Performing a hepatectomy after a laparoscopic splenectomy.

Hepatectomy for cirrhotic patients with hypersplenism is a high-risk operative procedure. We report herein a new strategy for high-risk patients with hepatocellular carcinoma (HCC). Six cirrhotic patients with HCC and hypersplenism received a partial hepatectomy after first undergoing a laparoscopic splenectomy. We then compared the variables for these patients before splenectomy and before hepatectomy. The platelet count and the white blood cell count were found to be significantly elevated before hepatectomy. The ammonia value decreased significantly before hepatectomy. The albumin value tended to be elevated before hepatectomy. Furthermore, the Child's classification of all patients improved significantly before hepatectomy. However, other variables-such as the indocyanine green dye excretion test at 15 min and the bilirubin value-did not change after splenectomy. For hepatectomy patients who first underwent a laparoscopic splenectomy, operation time ranged from 265 to 440 min (average time, 361 min), and blood loss ranged from 500 to 2,200 ml (median volume, 1,300 ml). Four of six patients did not require any blood transfusion; furthermore, no patient needed a platelet-rich plasma transfusion. All but one patient, who suffered postoperatively from an intractable duodenal ulcer, had an uneventful postoperative course. Partial hepatectomy after an initial laparoscopic splenectomy is a new and effective choice of treatment for cirrhotic patients with HCC and hypersplenism.

Perforated Pyloroduodenal Ulcers Long-Term Results with Omental Patch Closure and Parietal Cell Vagotomy

The authors evaluated parietal cell vagotomy and omental patch closure as treatment for perforated pyloroduodenal ulcers. Since the beginning of the century, there has been a difference of opinion as to whether perforated pyloroduodenal ulcers are best managed with nonoperative treatment, simple closure, or definitive treatment, i.e., a procedure that handles the emergency problem and simultaneously provides protection against further ulcer disease. The criticism of using definitive treatment at the time of perforation has been that some patients who might not have recurrent ulcer, if a definitive operation was not performed, would be at risk of adverse postoperative sequelae, including death. Parietal cell vagotomy as treatment of intractable duodenal ulcer disease was shown to be almost without complications. The objective of this study was to determine if the operation was equally applicable to perforated pyloroduodenal ulcers. A group of 107 selected patients with perforated pyloroduodenal ulcers underwent definitive treatment by omental patch closure and parietal cell vagotomy. The patients were evaluated prospectively on an annual basis up to 21 years. Gastric analyses were performed on each visit for which the patient gave his/her consent. Patients suspected of a recurrent ulcer were examined endoscopically for verification. There was one death (0.9%). Ninety-three patients were observed for follow-up for 2 to 21 years. The recurrent ulcer rate by life table analysis was 7.4%. The reoperative rate was 1.9%. Postoperative gastric sequelae were insignificant. All but four patients were graded Visick I or II at the time of their last evaluation. This study confirms that the combination of parietal cell vagotomy and omental patch closure is an excellent choice for treatment of patients with perforated pyloroduodenal ulcers, who, by virtue of their age, fitness, and status of the peritoneal cavity are candidates for definitive surgery. Virtually none of the morbidity that occurs with other forms of definitive treatment is inflicted on patients who might never have needed a definitive operation if simple closure was performed. At the same time, it provides definitive therapy for the larger number of patients who subsequently would have required a second operation for continued ulcer disease if simple closure alone was performed. Whether this operation is performed at the time of perforation should depend on the presence or absence of risk factors, rather than whether the ulcer is acute or chronic.

Current Surgical Management Of Duodenal Ulcers

The optimal treatment of duodenal ulcer disease today requires familiarity with a variety of operative approaches. Experience and judgment are needed to select the best procedure for the individual patient presenting with a specific ulcer complication. Improved medical therapy has relegated surgery largely to the role of emergency life-saving intervention. Nonetheless, the goal of surgery remains cure of the ulcer diathesis with avoidance of postoperative side effects. Toward this end, proximal gastric vagotomy has proved itself to be the operation of choice, not only for intractable pain, but also for perforation and perhaps for bleeding in selected good-risk patients. Its efficacy in the treatment of obstructing duodenal ulcer has not been demonstrated. Modifications of proximal gastric vagotomy, including the use of laparoscopic techniques, are currently being evaluated in patients with intractable duodenal ulcer pain.

Cure of duodenal ulcer associated with eradication of Helicobacter pylori

50 patients with intractable duodenal ulcer were randomly assigned to 4 weeks of treatment with colloidal bismuth subcitrate (CBS) alone (26 patients) or with amoxicillin and metronidazole (24 patients). 5 patients (all on triple therapy) withdrew because of side-effects. In 17 of the 45 patients who completed the treatment, Helicobacter pylori was eradicated, and there was no ulcer relapse during the first 12 months of follow-up. The ulcer relapse rate was significantly higher (17 of 21 [89%]) among patients who remained positive for H pylori. 9 patients who remained positive for H pylori and had ulcer relapses within 6 months of treatment with CBS alone, were subsequently given triple therapy. 7 of the 9 showed H pylori eradication and no relapses within the next 12 months. The 2 patients still H pylori-positive after triple therapy had further ulcer relapses. H pylori eradication, without altering acid output, will become the mainstay of duodenal ulcer treatment because it cures the disease.

Gastroduodenal ulcer. Overview of 150 papers presented before the Southern Surgical Association 1888-1986.

By the early part of this century, members of the Southern Surgical Association as well as others began to realize that gastroenterostomy alone was unacceptable for the treatment of gastric ulcer. Ulcer excision and some type of limited resection was advised. At a later date, gastric resection of varying extent, depending on ulcer size and location, became the appropriate treatment for complications of this disease. For treatment of complications of duodenal ulcer, gastroenterostomy was widely used from the latter part of the 19th century until the late 1930s. Adequate gastric resection slowly but cautiously replaced gastroenterostomy during the 1940s. Vagotomy with drainage and vagotomy with antrectomy slowly developed and replaced adequate resection by the early 1970s. Beginning in the 1970s and extending into the 1980s, fewer duodenal ulcers were seen, and many of those encountered were being adequately managed using the H2 receptor blockers. For the intractable duodenal ulcer there is currently an increasing trend to use the less invasive operation of parietal cell vagotomy. Vagotomy with antrectomy for such cases is being used less frequently. Vagotomy and drainage has lost much of its appeal. Lesser procedures have been advocated recently for treatment of marginal ulcer after incomplete vagotomy irrespective of the original operation for ulcer. Massive bleeding and acute perforation are still frequently encountered as complications but are being seen more frequently in elderly high-risk patients, some of whom will tolerate only a lesser procedure as suture ligation, vagotomy with drainage, or simple ulcer closure. It appears that we are now seeing a different duodenal ulcer pattern in the good-risk patient. The ulcers are usually small, less virulent, and less likely to be found penetrating into the pancreas and adjacent organ structures. As Claude Welch so aptly stated recently before the Association, "We are seeing a trend in ulcer surgery that is currently being seen in other areas of surgical endeavors as well." He emphasized that we must be alert to changing disease patterns and adapt our procedures to new requirements.

What is an intractable duodenal ulcer and how should it be managed?

An intractable duodenal ulcer is an ulcer that has not healed after 8 weeks of full-dose treatment with a modern anti-ulcer drug. Such ulcers are relatively rare--perhaps five in 100 patients will have intractable duodenal ulceration. The differential diagnosis includes non-compliance as a cause of continuing ulceration, hypersecretion of gastric acid or other rare causes of ulcers in the duodenum. Investigations should include biopsy of the continuing ulceration at endoscopy, measurement of fasting plasma gastrin and routine haematology and biochemistry profiles. An intractable duodenal ulcer can be treated either by using a powerful antisecretory regimen (high doses of ranitidine or famotidine or a conventional dose of omeprazole), by changing to tripotassium dicitrato bismuthate or, in exceptional circumstances, by extremely careful surgical intervention.

The history of vagotomy

The anatomic characteristics of the vagus nerve were described by Galen in the second century ad, and its physiology was studied by Pavlov almost a century ago. Therapeutic possibilities of vagal denervation of the stomach was explored by several surgeons in the first quarter of this century. The most auspicious effort was that of Latarjet. The rebirth of vagotomy in 1943 by Dragstedt was based on cumulative new data supporting the concept that vagal denervation should favorably influence the clinical course of duodenal ulcer. This now proved concept renders vagotomy in some form a basic part of all operations for duodenal ulcer. The Dragstedt operation, vagotomy and pyloroplasty, is particularly useful in cases of acute bleeding and obstruction. Vagotomy and antrectomy has the lowest ulcer recurrence rate. Parietal cell vagotomy has the lowest mortality and morbidity rates and is the procedure of choice in patients with uncomplicated, intractable duodenal ulcer.

Parietal cell vagotomy for intractable and obstructing duodenal ulcer

Parietal cell vagotomy can be accomplished with minimal morbidity and mortality. Symptoms and signs of delayed gastric emptying early after operation are common and occur more frequently in patients with preoperative gastric outlet obstruction than in those without, a difference that is statistically significant. These symptoms are generally mild and transient. Dumping and diarrhea were not problems in our series. In patients with preoperative gastric outlet obstruction, parietal cell vagotomy with pyloroduodenal dilatation achieved good or excellent results in 79 percent of patients; however, the possibility of a higher recurrence rate requires further evaluation and suggests caution and selectivity in the use of this procedure. The recurrence rate of 3 percent in patients without gastric outlet obstruction and a very good or excellent clinical result in 91 percent of these patients appear acceptable and encourage us to continue to use parietal cell vagotomy as the procedure of choice in patients with intractable duodenal ulcer. Most patients with recurrent ulcer have been treated medically with success. Close long-term clinical follow-up studies will be required to assess better the success of this procedure.

Pap Smears: Physicians Must Disclose Risk of Refusal

In 1972 the California Supreme Court helped set the standard for informed consent in the landmark case of Cobbs v. Grant. That case involved a middleaged gentleman who was operated on for an intractable peptic duodenal ulcer. He suffered complications which included loss of his spleen, a subsequent gastric ulcer, and a 50% gastrectomy. None of these well-recognized potential risks of ulcer surgery had been disclosed to him. The court determined that physicians must disclose the following information to patients, in lay terms, before performing procedures on them:a description of the procedure and its success rates;risks of death or serious bodily harm;alternatives, and the dangers inherent in each; andmajor problems of recuperation.

Parietal Cell Vagotomy

Although long-term follow-up data have not been obtained, it appears that parietal cell vagotomy for the treatment of intractable duodenal ulcer is withstanding the test of time. Operative mortality and morbidity are low, as is the incidence of side effects. The majority of patients who have a recurrent ulcer improve with medical therapy, and only a minority require reoperation.

A study of psychological factors in patients with surgically intractable duodenal ulcer and those with other intractable disorders.

A study of psychological factors in patients with surgically intractable duodenal ulcer and those with other intractable disorders.

Early history variables in predicting surgical success for intractable duodenal ulcer patients.

This study is concerned with the reported early experiences with parents of intractable duodenal ulcer patients, all male veterans. Rated life history variables are used to compare surgical successes and failures. The method for obtaining ratings on the variables was the use of a specially devised research-oriented interview found to yield satisfactory reliability. One variable, Displays of Affection from Mother, met the criterion of significance, and maintained it through replicated experiments. This variable significantly differentiated between surgical successes and failures those patients previously unpredictable from cross-sectional study.

Antral Duplication With Intractable Duodenal Ulcer: Report of case raising the possibility of antral hyperfunction

Antral Duplication With Intractable Duodenal Ulcer: Report of case raising the possibility of antral hyperfunction

AN EVALUATION OF GASTRIC HYPOTHERMIA.

Gastric “cooling” is an acceptable, sustaining procedure beneficial in the control of upper gastrointestinal bleeding of known or obscure origin. In its present mode of application, gastric “freezing” is not entirely satisfactory for management of intractable duodenal ulcer. This technic inconsistently alters symptoms of ulcer, causes acute gastric mucosal damage, and may so influence some factor related to ulcer diathesis as to provide adjunctive therapy. Gastric “freezing” is deserving of further evaluation and development under more rigidly controlled circumstances.