Management Of Peptic Ulcer Disease Research Articles

Awareness of Peptic Ulcer Disease among the General Population in Al-Ahsa.

Peptic ulcer disease (PUD) is a condition characterized by discontinuity in the gastrointestinal (GI) tract's inner lining, often caused by factors such as Helicobacter pylori infection and NSAID consumption. PUD can lead to various symptoms, but up to 70% of patients may not experience any symptoms. Diagnosing PUD can be challenging due to the unreliability of individual symptoms and signs. PUD can have serious complications if left untreated. Despite its significance, there is a lack of studies measuring the awareness of PUD among the population in Al-Ahsa, Saudi Arabia. Therefore, this study aimed to assess the level of awareness of PUD among the general population in Al-Ahsa. A cross-sectional study was conducted in Al-Ahsa, Saudi Arabia, from September to December 2023. The study included 399 adult residents of Saudi Arabia who agreed to participate. A convenient nonprobability sampling technique was used to collect data. An online self-administered questionnaire, distributed through social media platforms, was used to gather information on participants' awareness of PUD. The questionnaire included sociodemographic characteristics and questions related to PUD awareness. Data were analyzed using SPSS, and qualitative data were presented as numbers and percentages. The Chi-square test was used to examine qualitative data between the two groups. Of the 399 participants, 71.4% demonstrated a good level of knowledge regarding PUD, whereas 28.6% had a low level of knowledge. The sample consisted of nearly equal numbers of males and females, with participants aged 18-55+ years. The majority of participants had attained a bachelor's degree and were employed. The findings suggest a relatively high level of education among the study population. The study highlights the need for increased public awareness of PUD in Al-Ahsa, Saudi Arabia. While some participants showed good knowledge of PUD, a significant number had low awareness. Educational initiatives are essential to improve understanding and knowledge of PUD among the community. By enhancing awareness, early detection and appropriate management of PUD can be promoted, resulting in improved health outcomes for individuals in Al-Ahsa.

Comparative Effect of Curcuma longa and Piper nigrum Extract and their Mixture on some Gastric Secretory Parameters of Indomethacin-induced Gastric Ulceration in Albino Rats

Peptic ulcer disease (PUD) which includes gastric and duodenal ulcer is one of the unresolved medical problems facing numerous patients in a wide range of age of both sexes worldwide. Many medicinal plants are known to exhibit antiulcer activity and some have been confirmed scientifically to possess gastro protective and antiulcer property and also found to be useful in its treatment. Among these medicinal plants turmeric (Curcuma longa) and black pepper (Piper nigrum) have been reported to possess gastroprotective potentials. However, the effect of the combination of turmeric and black pepper on some gastric secretory parameters of ulcerated rats hasn’t been considered. As a result, this study was designed to evaluate the effect of ethanol extract of Curcuma longa and Piper nigrum on some gastric secretory parameters of indomethacin induced gastric ulceration in albino rats. Total of sixty (60) albino rats was used for this study. After acclimatization for 14 days, the animals were randomly allocated into six groups (n=10).Group A (normal control): rats was fed on pellet and allowed free access to water, rats in Group B (Ulcerated control) were given only indomethacin at a dose of 50mg/Kg body weight. Animals in group C (Standard control) was given indomethacin after pre treatment with esomperazole (20mg/kg) body weight. Group D, E, and F comprised ulcerated rats pre treated with turmeric (200mg/kg body weight), black pepper (100mg/kg body weight), turmeric and black pepper (200mg/Kg + 100mg/kg respectively) body weight. Treatments with the reference drug and extracts lasted for 21 days prior to ulcer induction on the twenty-third day.4 h post ulcer induction, the animals were humanely sacrificed under chloroform anaesthesia and gastric content drained into a centrifuge tube for further studies on some gastric secretory parameters. The study showed that TA levels were significantly (p < 0.05) higher in group B compared to the control group and all other groups. Conversely, TA levels were significantly (p < 0.05) lower in groups C, D, E, and F compared to the control, with group F showing the lowest levels among these, particularly lower than groups C and E. GpH levels were significantly (p < 0.05) lower in group B when compared to groups C, D, E, and F. However, GpH levels were significantly (p < 0.05) higher in groups D and E compared to the control, with group E having higher GpH levels than group C. Additionally, pepsin levels were significantly (p < 0.05) elevated in group B relative to the control and other groups. Pepsin levels were also significantly (p < 0.05) higher in groups C, D, E, and F compared to the control, with group C having lower levels than groups D and E. It can therefore concluded based on the findings of this study that the combination of turmeric and black pepper extract had more gastroprotective effect than the individual extracts alone suggestive of the synergistic effect of these plants in the management of peptic ulcer disease. Keywords: Curcuma longa, Piper nigrum, Indomethacin and Gastric Ulceration

The application of ginger supplementation on peptic ulcer disease management: A randomized, double blind, placebo-controlled clinical trial

The application of ginger supplementation on peptic ulcer disease management: A randomized, double blind, placebo-controlled clinical trial

Gastroprotective Effect of oenothein B: a Romising Macrocyclic Ellagitannin

A peptic ulcer disease is a significant gastrointestinal disorder with a high prevalence of 80% in developing countries and 40% in developed countries. Oenothein B, a macrocyclic ellagitannin, has emerged as a potential therapeutic agent for this condition. The aim of this study was to investigate the anti-ulcer activity of Oenothein B and elucidate the underlying mechanisms involved in its gastroprotective effects. The anti-ulcer activity of Oenothein B was assessed using various experimental models, including ulcers induced by indomethacin, HCl/ethanol, and pyloric ligation. Several parameters were evaluated, including the quantification of volume, pH, total gastric acidity secretion, as well as catalase and superoxide dismutase activity. The role of prostaglandins in mediating the effects of Oenothein B was also examined. The results demonstrated that Oenothein B exhibited significant anti-ulcer activity when administered intraduodenally at a dose of 15 mg/kg in an acute protocol of induced ulcers. This treatment resulted in a reduction in volume and total gastric acidity secretion. Moreover, oral administration of Oenothein B was found to increase catalase and superoxide dismutase activity in the gastric mucosa. These findings suggest that Oenothein B exerts its anti-ulcer effects by reducing gastric acid secretion and enhancing the activity of antioxidant enzymes. Additionally, the modulation of endogenous prostaglandin levels appears to play a role in mediating these effects. In conclusion, Oenothein B demonstrates promising anti-ulcer activity and may serve as a potential therapeutic option for the management of peptic ulcer disease. Further investigations are warranted to elucidate the detailed mechanisms of action and evaluate its efficacy and safety in clinical settings.

The management of peptic ulcer disease using conventional methods, bioactive compounds and dietotherapy: A review

Purpose of review: The management of Peptic Ulcer Disease (PUD) is achieved using pharmacological agents to counteract the aggressive factors or stimulate the mucosal defence. In recent years, plant-based bioactive products have gained popularity as an alternative management protocol due to the increased antibiotic resistance of Helicobacter pylori (H. pylori), lower cost, perceived effectiveness, availability, and little side effects. In this review, we summarized the conventional treatment methods, alternative bioactive compounds, and the dietotherapy of PUD.

Treatment Approaches Towards the Management of Peptic Ulcer Disease in a Resource Constrained Setting

Treatment Approaches Towards the Management of Peptic Ulcer Disease in a Resource Constrained Setting

Human Immunodeficiency Virus and Hepatitis C Virus-related Disparities in Undergoing Emergency General Surgical Procedures in the United States, 2016-2019.

To determine whether people living with human immunodeficiency virus (PLWHIV) and people living with hepatitis C virus (PLWHCV) experience inequities in receipt of emergency general surgery (EGS) care. PLWHIV and PLWHCV face discrimination in many domains; it is unknown whether this extends to the receipt of EGS care. Using data from the 2016 to 2019 National Inpatient Sample, we examined 507,458 nonelective admissions of adults with indications for one of the 7 highest-burden EGS procedures (partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, or laparotomy). Using logistic regression, we evaluated the association between HIV/HCV status and the likelihood of undergoing one of these procedures, adjusting for demographic factors, comorbidities, and hospital characteristics. We also stratified analyses for the 7 procedures separately. After adjustment for covariates, PLWHIV had lower odds of undergoing an indicated EGS procedure [adjusted odds ratio (aOR): 0.81; 95% CI: 0.73-0.89], as did PLWHCV (aOR: 0.66; 95% CI: 0.63-0.70). PLWHIV had reduced odds of undergoing cholecystectomy (aOR: 0.68; 95% CI: 0.58-0.80). PLWHCV had lower odds of undergoing cholecystectomy (aOR: 0.57; 95% CI: 0.53-0.62) or appendectomy (aOR: 0.76; 95% CI: 0.59-0.98). PLWHIV and PLWHCV are less likely than otherwise similar patients to undergo EGS procedures. Further efforts are warranted to ensure equitable access to EGS care for PLWHIV and PLWHCV.

PDE5 inhibitors and gastric mucosa: implications for the management of peptic ulcer disease.

Peptic ulcer disease (PUD) continues to be a cause of significant morbidity and mortality worldwide. Almost two-thirds of PUD cases are asymptomatic. In symptomatic patients, epigastric pain is the most common presenting symptom of PUD, which is manifested by nausea, abdominal fullness, bloating, and dyspepsia. Most PUD cases are associated with the use of COX inhibitors or Helicobacter pylori infection, or both. The traditional management of PUD includes the use of proton pump inhibitors to reduce the gastric acid secretion and antibacterial drugs to combat H. pylori. Timely diagnosis and treatment of PUD are vital to reduce the risk of associated morbidity and mortality, as is prevention of PUD among patients at high risk, including COX inhibitors users and those infected with H. pylori. PDE5 inhibitors have been used for the management of erectile dysfunction and pulmonary hypertension for decades. In recent years, studies have mentioned tremendous pleiotropic effects of PDE5 inhibitors on gastrointestinal, urogenital, musculoskeletal, reproductive, cutaneous, and neurologic disorders. Recent data shows that PDE5 inhibition augments gastric mucosa protection, and here, we review the most recent findings regarding the use of PDE5 inhibitors for the prevention and management of PUD.

S1631 Education on the Treatment of Helicobacter pylori Infection Improves Clinician Knowledge

Introduction: The prevalence of Helicobacter pylori infection in US adults is around 35%. Eradication of H. pylori is essential to the successful management of peptic ulcer disease, and the potential prevention of gastric cancer. The goal of this project was to assess the role of continuing medical education (CME) on improving learners’ knowledge regarding evidence-based treatment of H. pylori infection. Methods: Gastroenterologists (N =1499) and primary care physicians (PCPs; N =1224) participated in an online text-based CME/CE activity on the diagnosis and treatment of H. pylori infection (1). Educational effect was assessed using a repeated-pair design with pre-/post-assessment and 2 multiple choice questions. This assessed knowledge and included evaluation questions that gauged patient numbers and overall satisfaction with the education. We calculated relative improvement ([post%-pre%]/pre%) to examine change in percentage of correct responses. We used the chi-squared test for significance testing on the number of correct responses pre- to post-activity with P < 0.05 considered statistically significant. The online CME activity launched on October 15, 2021; data were collected on May 31, 2022. Results: Sixty-six percent of gastroenterologists and 60% of PCPs strongly agreed that this education increased their knowledge regarding evidence-based treatments for H. pylori infection. First line therapy for H. pylori infection: Gastroenterologists had a 308% relative increase (13%/53% pre/post; P < .05), and PCPs had a 360% relative increase (10%/46%, pre/post; P < .05) in knowledge regarding recommended first-line treatment of H. pylori infection (Figure). Antibiotic resistance and H. pylori treatment: Gastroenterologists had a 33% relative increase (55%/73%, pre/post; P < .05), and PCPs had a 162% relative increase (26%/68%, pre/post; P < .05) in knowledge about antibiotic resistance to clarithromycin in patients with H. pylori infection (Figure). Conclusion: We found significant improvement in knowledge among gastroenterologists and PCPs regarding evidence-based management of H. pylori infection. However, additional educational effort is required to close some clinical knowledge gaps regarding selection of first-line treatment for H. pylori infection and resistance to antibiotics, with particular emphasis on clarithromycin.Figure 1.: Pre and Post results for gastroenterologists and primary care physicians knowledge for first-line treatment of Helicobacter pylori.

The bacteriostatic property of melatonin targets peptic ulcer disease and cholangiocarcinoma

The marked drop in the frequency of Helicobacter pylori infection resulting from the use of antibiotics and potent anti-acid medications has substantially lowered the prevalence of peptic ulcer disease in recent decades. Management of this condition, however, is challenging because of the escalating perils of antibiotic resistance and the abuse of anti-inflammatory drugs. For example, the increased prevalence of cholangiocarcinomas may associate with this peptic ulcer disease management including the prolonged use of proton pump inhibitors. Cholangiocarcinoma is one of the most lethal cancers and accounts for almost 15% of all hepatic malignancies. This review provides a concise summary of the latest findings in the pathogenetic mechanisms of cholangiocarcinoma, essentially focusing on peptic ulcer disease and its associated therapies. We also suggest interventions that may reduce Helicobacter pylori infection and peptic ulcers with the bacteriostatic agent, melatonin. Melatonin treatment may reduce the incidence of this devastating cancer or improve the outcome of individuals that develop this disease.

Emerging Trends and their Impacts on Peptic Ulcer Diseases: Treatments and Techniques

Background: Peptic ulcer disease (PUD) is prevalent in almost all parts of the world. PUD complications are creating a major source of preventable health care expenses. The major factors responsible for the incidence of PUD and its complication have changed over the past few decades after the identification of non-steroidal inflammatory drugs (NSAIDs) and Helicobacter pylori bacterial infection along with a marked increase in the use of proton-pump inhibitors (PPIs) as drug therapy. The management of PUD has become more complex and challenging due to antimicrobial resistance. Objective: The objective of the study was to highlight current therapy and novel techniques used in the treatment of peptic ulcer diseases. Methods: An exhaustive literature search has been conducted across PubMed, Google, Scopus and Web of Science as an electronic database to add the crucial information from the relevant literature. Results: In the present review, we have discussed PUD and its pathophysiology. The recent trends in PUD and possible treatments with novel techniques have also been discussed. The type and presence of ulcers cannot be predicted accurately based on symptoms. The available treatment approaches for peptic ulcers based on their clinical presentation and etiology are anti-secretary therapy, endoscopy to reveal ulcers followed by drug therapy, and triple therapy for H pylori infection. Conclusion: Thus, the popular and effective methods are very beneficial in controlling PUD. The treatment based on diagnosis is the foremost requirement for ameliorating any disorder. In this article, the emerging techniques and development in the treatment and diagnosis of PUD have been reviewed.

Hospital Volume of Emergency General Surgery and its Impact on Inpatient Mortality for Geriatric Patients: Analysis From 3994 Hospitals.

Previous investigations have shown a positive association between hospital volume of operations and clinical outcomes. However, it is unclear whether such relationships also apply to emergency surgery. We sought to examine the association between hospital case volume and inpatient mortality for 7 common emergency general surgery (EGS) operations among geriatric patients. This is a population based retrospective cohort study using the Centers of Medicare and Medicaid Services (CMS) Limited Dataset Files (LDS) from 2011 to 2013. The 7 most common emergency surgeries included (1) partial colectomy, (2) small-bowel resection (SBR), (3) cholecystectomy, (4) appendectomy, (5) lysis of adhesions (LOA), (6) operative management of peptic ulcer disease (PUD), and (7) laparotomy with the primary outcome being inpatient mortality. Risk-adjusted inpatient mortality was plotted against operative volume. Subsequently an operative volume threshold was calculated using a best fit regression method. Based on these estimates, high- and low-volume hospitals were compared to examine significance of outcomes. Significance was defined as P-value < .05. The final cohort comprised of 414779 patients from 3994 hospitals. The standardized mortality ratio (SMR) for high-volume centers were lower in 6 out of 8 surgeries examined. Small-bowel resection and partial colectomy operations had a significant decrease in mortality based on a volume threshold. We observed decreased mortality with higher surgical volume for small-bowel resection and partial colectomy operations. Such differences may be related to practice patterns during the perioperative period, as complications related to the perioperative care were significantly lower for high-volume centers.

Emergency General Surgery Procedures and Cost of Care for Older Adults in the State of Maryland.

Older adults (OAs) ≥ 65years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant. Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65years of age. These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.

Diagnosis and Management of Benign Gastric and Duodenal Disease

The diagnosis of uncomplicated peptic ulcers is difficult to make on a solely clinical basis. Whereas radiographic upper gastrointestinal (UGI) series remain useful, endoscopy is the most accurate method of establishing the diagnosis of peptic ulcer disease. Laboratory tests play an important role in the diagnosis of Helicobacter pylori infection and Zollinger-Ellison syndrome. Figures showing UGI series with double contrast and H. pylori organisms on gastric biopsy samples are provided. The improved medical management of peptic ulcer disease has decreased the need for surgical intervention, which is now largely reserved for urgent management of complications such as hemorrhage, bleeding, and perforation, or the management of obstruction from intractable disease. The appropriate extent of preoperative evaluation for a patient undergoing surgery for a benign gastroduodenal disorder is dictated primarily by the nature of the presenting problem. Endoscopy is the main diagnostic tool to identify the source of bleeding, and in many cases endoscopic therapy can control the bleeding. Angiographic transarterial embolization may be considered following failed endoscopic hemostasis, particularly in high-risk surgical patients. Operative planning is described. The steps of the operative technique, complications, and outcome evaluations are provided for the main surgical interventions for peptic ulcer disease, including vagotomy and pyloroplasty for bleeding duodenal ulcer; resection of bleeding gastric ulcer; omental patch for duodenal perforation (Graham patch); antrectomy; highly selective vagotomy; laparoscopic treatment of peptic ulcer disease; and duodenal diverticulectomy. Operative figures show a Kocher maneuver; omental patch; truncal vagotomy; highly selective vagotomy; Taylor procedure; Heineke-Mikulicz pyloroplasty; Finney pyloroplasty; Billroth I and II antrectomy; Braun enteroenterostomy; and duodenal diverticulectomy. This review contains 15 figures, 2 tables, and 43 references.

EVALUATION OF THE ROLE OF LAPAROSCOPIC TRUNCAL VAGOTOMY AND GASTRO-JEJUNOSTOMY FOR CICATRIZED DUODENAL ULCER:A PROSPECTIVE STUDY

INTRODUCTIONPeptic ulcer affects about 5% of the global population. About 70-90% of patients with gastric ulcer and 80-95% with duodenal ulcers are infected with H. pylori.After the era of proton-pump inhibitor, management of peptic ulcer disease has changed dramaticallyand manifested by early satiety and fullness after meals and repeated vomiting. endoscopic balloon dilatation of pylorus followed by long term H2-receptor antagonists was suggested that surgery could be avoided in up to 80% of the patients,with longer follow up.Over50% will require ulcer surgery within two years of dilatation. In addition, the dilatation carries a risk of perforation rate up to 10%. Balloon dilatation is only reserved for those patients who are too high a risk surgery.AIM OF THE WORKThis study is designed to assess the role of laparoscopic truncal vagotomy and laparoscopic gastro-jujenostomy in the treatment of patient with gastric outlet obstruction due to cicatrized duodenal ulcer.Subjects and methodsAfter approval of local ethics committee, all patients included in the study will be informed about the procedure and will sign an informed written consent before carrying the procedureThis study will be concerned on 15 patients, in the upper gastrointestinal surgery unit, Alexandria main University Hospital presenting with gastric outletobstruction due to cicatrized duodenal ulcer confirmed by upper GI endoscope and C.T gastrography

Medicinal Plants with Prospective Benefits in the Management of Peptic Ulcer Diseases in Ghana.

Background The growth or multiplication of harmful microorganisms in addition to harmful human activities has led to many disorders in humans. Consequently, there is a search for medications to treat these disorders. Interestingly, medicines of plant origin are known to be among the most attractive sources of new drugs and have shown promising results in the treatment of various diseases including peptic ulcers. This review, therefore, is aimed at obtaining knowledge on some Ghanaian ethnomedicinal plants used to treat peptic ulcers, their folkloric uses, their phytochemicals, and their antiulcer and related pharmacological activities as well as finding areas for prospective studies.Methods Published peer-reviewed articles on ethnomedicinal plants used for the management of peptic ulcers in Ghana from 1967 to 2020 were sourced and used for the study. Results In this review, 13 plants were identified which belong to 10 different families including Sapindaceae, Apocynaceae, and Bignoniaceae. The parts most often used for most preparations were the leaves (53%), followed by stem bark and roots (both having the same percentage of use of 17.6%), the whole plant (5.9%), and the rhizomes (5.9%). Azadirachta indica was the only plant that had undergone some patient studies in addition to animal studies. Conclusion. A discussion of various antiulcer activity studies using ulcer models carried out on selected medicinal plants used for the management of peptic ulcer disease in addition to brief information on their folkloric uses and their phytochemical and other pharmacological properties is presented. These medicinal plants may be used in developing herbal products for the management of peptic ulcer disease.

Peptic ulcer disease

Peptic ulcer disease (PUD) is defined as a disruption in the innermost lining of the gastrointestinal tract, due to the secretion of gastric acid or pepsin. The disruption is in the gastric epithelial layer, specifically the muscularis mucosae. PUD normally affects the stomach along with the first and second parts of the duodenum, although it is not limited to these areas. Typically, gastric ulcers induce upper abdominal pain within 30 minutes of eating, whereas duodenal ulcers cause discomfort much later. Endoscopic and histological investigations are the key to early identification and treatment of patients with PUD, with testing for Helicobacter pylori necessary in those patients suspected of having PUD. In this article we will be looking at the aetiology, pathophysiology and management of PUD.

Challenges in the Management of Peptic Ulcer Disease

Challenges in the Management of Peptic Ulcer Disease

S1869 Transoral Gastric Outlet Reduction in a Patient With Billroth II Anastomosis for the Treatment of Severe Bile Acid Reflux

INTRODUCTION: Endoscopic transoral outlet reduction (TORe) utilizing a full thickness endoscopic suturing device is a minimally invasive therapeutic option in bariatric surgery patients who have experienced weight gain. This procedure can be therapeutic not only for weight gain after Roux-en-Y Gastric Bypass (RYGB), but also can be used in patients who underwent Billroth II procedure with biliary reflux symptoms. CASE DESCRIPTION/METHODS: A 68-year-old female patient with a past medical history of hypertension, dyslipidemia and prior Billroth II procedure for management of peptic ulcer disease presented with severe epigastric pain and bloating after meals refractory to PPI use. She underwent an EGD and was diagnosed with severe biliary gastritis. Transoral endoscopic gastric outlet reduction was recommended for this patient. A diagnostic flexible endoscope was advanced to the site of gastroduodenal anastomosis. Then, the gastric mucosa on the side of the anastomosis was aggressively ablated using argon plasma coagulation (APC). An endoscopic scissor was then used for trimming the previous suture remnants. A double channel scope was then inserted with the OverStitch device. A 2-0 Prolene suture was placed at the 3 O'clock position using full thickness running suture technique. A total of 4 bites were used. The suture was subsequently tightened with the creation of pseudo-pyloric opening. A total of one cinch was deployed to keep the suturing material permanently reinforced. No complications occurred throughout the procedure. Post-procedure follow up was normal with complete resolution of the patient's symptoms. DISCUSSION: Transoral endoscopic gastric outlet reduction is an emerging procedure used to manage weight gain after RYGB. The two-fold running suture technique is a novel method that can be used very effectively in this procedure. We have demonstrated that transoral outlet gastric reduction is not only effective for patients who have gained weight after RYGB, but also therapeutic in the improvement of biliary reflux symptoms after Billroth II procedure.Figure 1.: Argon plasma coagulation of the anastomotic margin.Figure 2.: Endoscopic suturing using the Apollo OverStitch device.Figure 3.: Creation of pseudo-pyloric opening.

Clavulanic Acid in the Scope of Helicobacter pylori Treatment: A Literature Review and Beyond.

Helicobacter pylori (H. pylori) infection is the most common cause of peptic ulcer disease and it can be associated with many complications, including malignancies. In clinical practice, some clinicians may use Clavulanic Acid (CA) in combination with amoxicillin or other beta-lactams as an addition to the standard treatment regimens. This practice may be done by habitual mistake, non-evidence based hypothetical assumptions, or by prescribing it as an alternative treatment. This review aims to expose the effect of CA against H. pylori infection and to review the possible mechanisms that may contribute to that effect. A PubMed and Google Scholar literature search was obtained on both pre-clinical and clinical studies related to CA and H. pylori infection. Available clinical studies showed improvement in the eradication of H. pylori by about 10- 20% when CA was added to the treatment regimens. This effect for CA could be related to several mechanisms including inhibition of H. pylori growth by binding to Penicillin-Binding Proteins (PBPs), the transformation of H. pylori from the active filamentous form into coccoidal form, induction of the release of dopamine, modulation of immunological response towards H. pylori infection and its relationship with other microbiota. Randomized-controlled studies on patients with resistance to H. pylori are needed. Moreover, in vitro studies to evaluate the mechanisms by which CA may influence H. pylori are warranted. The presented literature suggests potential avenues for the use of CA in the management of peptic ulcer disease and H. pylori infection.