Intractable Gastric Ulcer Research Articles

腹壁瘢痕ヘルニアが原因と考えられた難治性胃潰瘍の1例

症例は67歳，女性．6年前，十二指腸潰瘍穿孔で緊急開腹穿孔部閉鎖術を受けた．その1年後から，上腹部正中切開創に一致した膨隆が出現．さらに3年後に，胃幽門部潰瘍を指摘され内科的治療を継続していたが，治癒傾向が乏しく難治性胃潰瘍の原因として腹壁瘢痕ヘルニアが疑われ当科へ紹介受診となった．胃内視鏡検査では幽門輪部にA2 stage潰瘍を認めた．腹部造影CT検査では上腹部正中に7×6cmのヘルニア門より幽門前庭部が脱出し，右胃大網静脈に造影剤の停滞を認めた．以上の所見から，胃の一部が脱出する腹壁瘢痕ヘルニアにより右胃大網静脈のうっ滞が生じ胃潰瘍治癒が遷延していると考え，腹壁瘢痕ヘルニア修復術を施行した．術後41日目の胃内視鏡検査では，潰瘍底の大半が再生上皮に覆われS1 stageとなっていた．今回，腹壁瘢痕ヘルニア修復術により難治性胃潰瘍の治癒傾向が得られた1例を経験したので，その病態を中心に文献的考察を加え報告する．

Chronic active Epstein-Barr virus infection mimicking autoimmune hepatitis exacerbation in a patient with systemic lupus erythematosus

Chronic active Epstein-Barr virus infection (CAEBV) is characterized by chronic infectious mononucleosis-like symptoms. We report a very rare case with autoimmune hepatitis (AIH) complicated by CAEBV. A 50-year-old woman with systemic lupus erythematosus (SLE) complicated by AIH began to suffer from acute respiratory failure and her clinical symptoms improved rapidly in response to steroid treatment. However, during the gradual tapering of the steroid dose, a steady increase of the serum hepatobiliary enzyme levels subsequently was observed and the patient began to have continuous fever. Moreover, upper gastrointestinal endoscopy revealed multiple intractable gastric ulcers. When EBER-ISH was performed on liver biopsy and gastric mucosal biopsy specimens, EBER-positive lymphocytes were observed. When peripheral blood was examined, 2.1 × 10(6) copies/µg of EBV-DNA were observed in the CD4-positive T cells, confirming the diagnosis of CAEBV. A cooling therapy was started by steroid and cyclosporine. Thereafter, despite the start of CHOP therapy, she developed a malignant lymphoma (PTCL-NOS) and died of hepatic failure. When treatment-resistant AIH patients are encountered, not only AIH exacerbation but also CAEBV should be considered in the differential diagnosis.

Single-incision Laparoscopy-assisted Subtotal Gastrectomy for Intractable Gastric Ulcer

Single-incision laparoscopic surgery (SILS) offers excellent cosmetic results and may be associated with decreased postoperative pain and accelerated recovery. Although there have been reports of cholecystectomy and appendectomy using SILS, there have been few reports of gastric resection with intracorporeal reconstruction of the digestive tract using SILS. The first single-incision laparoscopic gastrectomy with intracorporeal reconstruction is reported. Preliminary experience with single-incision laparoscopic gastrectomy with intracorporeal reconstruction for a patient with an intractable gastric ulcer is reported. Single-incision laparoscopy-assisted subtotal gastrectomy and Roux-en-Y reconstruction were performed. Operative time for gastrectomy and paraduodenal hernioplasty was 412 minutes, and blood loss was 90 g. No intraoperative or postoperative complications developed. Single-incision laparoscopy-assisted gastrectomy for intractable gastric ulcer is technically feasible. Intracorporeal reconstruction of the digestive tract was performed safely using a linear endoscopic stapler. This surgical approach is a further advance toward scarless surgery of the stomach.

Resolution of Uncontrolled Type 2 Diabetes after Laparoscopic Truncal Vagotomy, Subtotal Gastrectomy, and Roux-en-Y Gastrojejunostomy for a Patient with Intractable Gastric Ulcers

Background. Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been shown to be an effective treatment for type 2 diabetes mellitus (T2DM) in patients with morbid obesity. However, it is unclear just how effective the LRYGB procedure is on T2DM for patients with BMI less than 35 kg/m2. We report one obese patient with T2DM who did not meet the current NIH criteria for morbid obesity surgery. This patient underwent a laparoscopic truncal vagotomy, subtotal gastrectomy, and Roux-en-Y gastrojejunostomy for intractable gastric ulcers and subsequently had full resolution of her T2DM. Methods. A 48-year-old patient with a BMI of 34.6 kg/m2 underwent a laparoscopic truncal vagotomy, subtotal gastrectomy, and Roux-en-Y gastrojejunostomy for intractable gastric ulcers. The patient was seen 3 months preoperatively, followed for 24 months postoperatively, and evaluated for postoperative complications, weight loss, and improvement in comorbidities. Results. The patient had no postoperative surgical complications. Her BMI decreased from 34.6 kg/m2 to 22.3 kg/m2 by 24 months postoperatively. Significant improvements in her fasting blood glucose levels were seen 10 days postoperatively from a preoperative level of 147 mg/dl to 97 mg/dl. Conclusion. Patients with a BMI less than 35 kg/m2 and uncontrolled T2DM may benefit from a laparoscopic Roux-en-Y gastric bypass.

A case of hypereosinophilic syndrome presenting withintractable gastric ulcers

We report a rare case of hypereosinophilic syndrome (HES) presenting with intractable gastric ulcers. A 71-year-old man was admitted with epigastric pain. Initial endoscopic findings revealed multiple, active gastric ulcers in the gastric antrum. He underwent Helicobacter pylori (H pylori) eradication therapy followed by proton pump inhibitor (PPI) therapy. However, follow-up endoscopy at 4, 6, 10 and 14 mo revealed persistent multiple gastric ulcers without significant improvement. The proportion of his eosinophil count increased to 43% (total count: 7903/mm(3)). Abdominal-pelvic and chest computed tomography scans showed multiple small nodules in the liver and both lungs. The endoscopic biopsy specimen taken from the gastric antrum revealed prominent eosinophilic infiltration, and the liver biopsy specimen also showed eosinophilic infiltration in the portal tract and sinusoid. A bone marrow biopsy disclosed eosinophilic hyperplasia as well as increased cellularity of 70%. The patient was finally diagnosed with HES involving the stomach, liver, lung, and bone marrow. When gastric ulcers do not improve despite H pylori eradication and prolonged PPI therapy, infiltrative gastric disorders such as HES should be considered.

Analysis of Toll-like receptor 2, 4, 6 and 9 genome DNA mutations in patients with tractable and intractable gastric mucosal diseases

The possible involvement of Toll-like receptor (TLR) genome DNA in the prolongation and relapse of inflammatory intestinal diseases and alcoholic hepatic diseases has been reported. In this study, we examined the relationship of mutations of the TLR 2, 4, 6 and 9 genomic DNA to recurrent or intractable gastritis or gastric ulcers. The subjects were 32 patients, including 6 with H. pylori (Hp)-positive gastritis, 4 with Hp-negative gastritis, 10 with Hp-positive tractable gastric ulcer, 5 with Hp-positive recurrent gastric ulcer after Hp eradication, and 7 with Hp-negative easily recurrent gastric ulcer after Hp eradication. Gastric mucosal tissue and peripheral blood specimens were collected from each of the patients. DNA was extracted from the tissue and blood specimens and subjected to electrophoresis by the PCR method, using the oligonucleotide primers of TLR 2, 4, 6 and 9. The gastric mucosal tissue specimens were collected endoscopically from the sites of the lesions. Subsequently, the presence or absence of genomic DNA mutations in the blood and tissue specimens was examined using a DNA sequencer. TLR 2, 4, 6 or 9 DNA mutations were not observed in any of the gastric mucosal or peripheral blood specimens obtained from patients with tractable gastritis or gastric ulcer, or from those with intractable gastric ulcer who were Hp-positive or Hp-negative or had become Hp-negative after eradication therapy. These data suggest that mutations of the TLR 2, 4, 6 and 9 genome DNA may not be involved in the recurrence, delayed healing or intractability of gastritis and gastric ulcers.

A case of early syphilitic hepatitis accompanied by intractable gastric ulcer

A case of early syphilitic hepatitis accompanied by intractable gastric ulcer

Evidence for participation of gliostatin/ Platelet-derived endothelial cell growth factor in gastric ulcer healing

Gliostatin (GLS)/Platelet-derived endothelial cell growth factor (PD-ECGF) is a protein factor that has angiogenic and thymidine phosphorylase activity. It has been recently demonstrated to be related to disease activity in rheumatoid arthritis. However, its physiological role in the gastric mucosa is unknown. In the present study, concentrations of this protein in human gastric mucosa and plasma were evaluated. Further, the effect of purified human GLS/PD-ECGF on experimental ulcer healing was investigated in the rat. The human plasma concentration of GLS/PD-ECGF was significantly higher in patients with intractable gastric ulcer than in patients with significant resolution. The tissue content was significantly higher at the gastric ulcer edge than in either the fundic or pyloric region. GLS/PD-ECGF infusion delayed ulcer healing in a dose-dependent manner. These results suggest that gastric tissue and/or circulating GLS/PD-ECGF may participate in pathology and etiology of gastric ulcers and that this mechanism may relate to the pathogenesis of RA.

Radiographic findings of intractable gastric ulcers with H2-receptor antagonists.

To clarify the radiographic characteristics of intractable gastric ulcers with H2-receptor antagonists. The radiographic findings at the time of starting treatment were compared between 42 patients with gastric ulcers that did not heal within eight weeks of starting treatment with H2-receptor antagonists (the intractable group) and 58 patients whose ulcers healed within the eight-week period (the tractable group). The following radiographic findings in the intractable group were observed at a significantly higher incidence than those in the tractable group and included: an ulcer located on the angle, linear ulcers, a greater depth, an uneven mound surrounding an ulcer, prominent folds' convergence, an overhanging gastric mucosa, an irregular ulcer base, a shortening of the lesser curvature and a U-shaped deformity of the angle. A multiple logistic regression analysis showed that the following three factors had a significant and independent delaying effect on healing: a U-shaped deformity of the angle, an uneven mound surrounding an ulcer and prominent folds' convergence. The relative risk of these factors were 12.7, 14.4 and 12.5, respectively. Intractable gastric ulcer with H2-receptor antagonists can be predicted based on the characteristic radiographic findings at the start of treatment.

Helicobacter pylori in intractable gastric ulcer and cagA gene.

Helicobacter pylori in intractable gastric ulcer and cagA gene.

Therapeutic Success with the Suppression of Helicobacter pylori of Intractable Gastric Ulcers

Abstract: Three patients with a long history of gastric ulcers refractory to treatment first with an H2‐receptor antagonist, then with a prostaglandin Et analogue plus an antagonist, and next with a proton‐pump inhibitor, lansoprazole, were given amoxicillin together with an H2‐receptor antagonist, and the ulcers finally healed. The patients were men aged about 60, and two were smokers. Reduction of gastric acidity by lansoprazole may have been satisfactory in these patients because one dose of the drug raised the gastric pH to more than 3.0 for about 97% of the next 24h in all three of the patients, as by the continuous measurement of intraluminal pH. The gastric mucosa of these patients was found to be infected with Helicobacter pylori when tested at the end of treatment with this inhibitor. Their medication was changed from the proton‐pump inhibitor to amoxicillin plus an H2‐receptor antagonist, and all of the ulcers healed within 6 weeks. H. pylori was not detected at the end of this treatment. These results indicate that reduction of gastric acidity alone was insufficient to cure the ulcers in these patients. H. pylori may be related to some ulcers being refractory to many antiulcer agents, even proton‐pump inhibitors.

Balloon sensors versus perfused side hole sensors for oesophageal manometry. A study in healthy volunteers

Objective: We have reported that monochloramine, a neutrophil-derived oxidant, was responsible for the experimental injury to gastric mucosal cells induced by Helicobacter pylori, and that taurine, a scavenger of the oxidant, reduced the injury. The objective of the present study was to endoscopically, histologically and microbiologically examine the effect of taurine on the human gastric mucosal lesions associated with H. pylori. Design and methods: We studied nine patients with H. pylori-associated intractable gastric ulcers who had shown no endoscopic improvement for at least 4 weeks (a control period) before the administration of taurine, and 12 patients with gastritis alone

A clinical study of pathophysiology and treatment of intractable gastric ulcers based on 24-hour intragastric pH monitoring

A clinical study of pathophysiology and treatment of intractable gastric ulcers based on 24-hour intragastric pH monitoring

Cell Proliferation Kinetics in the Marginal Mucosa of Gastric Ulcer Evaluated by Immunostaining of DNA Polymerase α

We studied the proliferative ability of the marginal mucosal cells surrounding the ulcer in the healing processes of gastric ulcers. We obtained a labeling index (LI) at the neck and generative zone of gastric pit using a monoclonal antibody against DNA polymerase alpha for tractable and intractable gastric ulcers located at the fundic mucosa during each endoscopic stage. The LI during the healing stage was higher than that during the active stage in both the tractable and intractable cases. However, in each stage, the LI of the tractable gastric ulcers was higher than that of their intractable counterparts. Finally, we analyzed the LI in tractable gastric ulcers after setting two groups: one treated with anti-ulcer drugs and the other untreated. There were no significant differences between these two groups. We believe that investigation of proliferative abilities in the marginal mucosa of gastric ulcers is important to understand the nature of gastric ulcers and to assess therapeutic efficacy.

Psychosomatic Studies on Intractable Gastric Ulcers by Famotidine

Psychosomatic Studies on Intractable Gastric Ulcers by Famotidine

Role of prostaglandin E2 on human gastric ulcers.

Using radioimmunoassay, we determined the mucosal prostaglandin E2 (PGE2) concentration in normal subjects and in patients with tractable and intractable gastric ulcers. The fundic and antral mucosa of the normal subjects contained large amounts of PGE2; they were not significantly different from those found in tractable and intractable gastric ulcer patients. The mucosal PGE2 concentration at the ulcer margin was significantly higher in tractable than intractable cases. To assess the effect of PGE2 on ulcer healing, 11 intractable ulcer patients received PGE2 (1.5 or 3.0 mg/day) perorally. In 7 (64%), the ulcer healed completely within 4 to 14 weeks.

Nd: YAGレーザーの生体に対する波長特性に関する研究

Our clinical experience has shown that intractable gastric ulcers can be healed effectively by Nd: YAG laser phototherapy. One of the mechanisms is a destructive effect on the fibrous tissue of the ulcers by high power densities of laser radiation. The other is a specific effect on it of the wave lentgh. However, these mechanisms are still unclear. The pourpose of this study is to make clear a specificity of the wave length of Nd: YAG laser in biological effect.Laser was radiated to the cultured canine hepatocytes in plastic culture dish at 50w of out put power, 5 second duration and 10cm of distance. Power densities were applied from 120 to 480 J/cm2 in this condition. The specific effect of the wave length was evaluated by the measurement of the viability of hepatocytes, the ability of 3H-thymidine and 14C-leucine up-takes after 24 hours of radiation.Temperature in the culture dish rose to approximately average of 44°C during radiation. Viability of hepatocytes was 94+1%before radiation and was 9511% after radiation with 480J/cm2. The ability of up-take of the radioisotopes showed no remarkable changes in comparison with non radiation group.These results suggest that the specific effect of the wave length is not essential on a healing of intractable ulcers in condition of usual clinical application of Nd: YAG laser.

LASER ENDOSCOPYの効用と限界-特に消化管の出血・腫瘍・潰瘍に関して

LASER ENDOSCOPYの効用と限界-特に消化管の出血・腫瘍・潰瘍に関して

Pylorus-preserving procedure in partial and total gastrectomy

1. The operative technique and the postoperative results of the original pylorus-preserving gastrectomy (PPG) and those of the Maki procedure as applied to cases of total gastrectomy are reported briefly. 2. The essence of these operations is to retain the pyloric cuff of 1.0-1.5 cm in length in order to preserve sphincteric function without the use of the drainage procedure. Ingested food was seen to empty gradually and rhythmically through the pyloric ring into the duodenum thereby avoiding dumping syndrome and reflux esophagitis. 3. As gastric acidity is reduced sufficiently by PPG, this method is to be recommended for treatment of intractable gastric ulcer cases and other benign lesions in which the foci are located in the distal half of the stomach. Though the method seems to be also useful in selected cases of duodenal ulcer, stenosis at the level of the pylorus and duodenum may preclude the application of the method. 4. The Maki procedure with jejunal interposition following nearly-total proximal gastrectomy is recommended in patients whose pylorus and its surroundings have remained free of tumor.

Gastrointestinal Sarcoidosis Diagnosed by Conjunctival Biopsy

Ophthalmologic examination of a 31-year-old black man presenting with an intractable gastric ulcer revealed small conjunctival nodules in the lower cul-desac that were sarcoid granulomas by microscopy. Previous endoscopic examination had revealed polyps in the gastric antrum, and a biopsy and microscopic examination had revealed granulomatous lesions, but a definite diagnosis could not be made until the ophthalmoscopic examination.