Previous History Of Peptic Ulcer Research Articles

P629 An uncommon cause for a frequent problem

Abstract Introduction Libman-Sacks endocarditis is the most characteristic cardiac manifestation of the autoimmune disease systemic lupus erythematosus. Embolic phenomena, although uncommon, can also complicate valvular abnormalities and can cause neurologic and systemic complications. Case Report Man, 52 years old. Active smoker and with previous peptic ulcer history. Admitted to our emergency department due to sudden onset of confusion and incoherent speech. The physical examination showed only a Glasgow Coma Scale of 9 and the presence of expressive aphasia. Normal pulmonary and cardiac auscultation, without any other pathological findings on physical examination. Investigations showed a normal EKG, chest X-Ray and arterial-blood gas test. Blood test showed only the presence of thrombocytopenia, leucocytosis and renal disfunction. Brain CT revealed left-sided thalamic lacunar lesion. We assumed an ischemic stroke and admitted the patient in our emergency department. Neurological deterioration in the first 24h. A new brain CT was performed and showed multiple lesions in the middle cerebral artery territory. The echocardiogram was performed and showed the presence of multiples vegetations in both mitral leaflets with moderate to severe mitral regurgitation associated. We assume an ischemic stroke in the context of possible infective endocarditis. Medical therapy was optimized and empirical antimicrobial therapy was started (ampicillin + gentamicin + flucoxacillin). The patient never had fever during hospital stay. Duke criteria with only 1 major criteria. Persistent negative microbiological cultures with decreasing inflammatory parameters. Blood tests revealed a progressive increase level of INR (2-4) and renal function deterioration. Patient began with massive episodes of diarrhea and sudden decrease of haemoglobin level (sudden reduction of 3g/dl). Endoscopic studies were performed and multiple ischemic lesions of embolic etiology and small vessel disease had been described. Serology test revealed a positive IgG for Mycoplasma pneumoniae. Autoimmune lab tests showed positivity for lupus anticoagulant, anticardiolipin and anti–beta-2 glycoprotein I. We discussed the clinical case with our autoimmune experts team and the diagnosis of Systemic Lupus Erythematosus + Antiphospholipid Syndrome + Libman-Sacks Endocarditis was assumed. The patient started immunosuppressive therapy (Azathioprine + Mycophenolate Mofetil + Prednisolone). Despite the used therapy the size of vegetation persisted and mitral regurgitation didn’t improve. In this context, the patient was presented to our cardiac surgery team and underwent surgical intervention (vegetation removal + mitral valve repair). Evaluation one year after surgery revealed progressive functional and echocardiographic improvement. Conclusion The authors presented a didactic clinical case where valvular surgery was required thanks to a hemodynamically significant valvular dysfunction and embolic events.

The incidence, clinical characteristics and risk factors of upper gastrointestinal bleeding in patients taking dual antiplatelet therapy after percutaneous coronary intervention in south China

To investigate the incidence, clinical characteristics and risk factors of upper gastrointestinal bleeding (UGIB) in patients with acute coronary syndrome (ACS) who were administrated with aspirin and clopidogrel dual antiplatelet therapy after percutaneous coronary intervention (PCI). ACS patients who had undergone PCI in the cardiovascular institute of Guangdong General Hospital from September 2009 to August 2014 were retrospectively enrolled.The incidence of UGIB and clinical characteristics of ACS patients on dual antiplatelet therapy for 1 year after PCI were analyzed.Risk factors of UGIB were screened in the cohort of patients and sex and age matched controls with ratio 1∶3. A total of 9 118 ACS patients had undergone PCI and UGIB occurred in 189 patients (2.07%, 189/9 118) from September 2009 to August 2014. UGIB patients with history over one year, gastrointestinal tumors or varices or negative endoscopy were excluded.Thus the revised incidence of UGIB occurred was 0.61% in 56 patients (0.61%, 56/9 118) and appeared to decline year by year.Most patients (91.07%, 51/56) had melena or stool occult blood positive (OB+ ), while others had bloody stool or haematemesis.Most UGIB were ulcer-related which was proved by endoscopy, accounting for 67.86% (38/56). There were 24 cases with duodenal ulcer, 13 with gastric ulcer and 1 with complex ulcer, while others were gastric erosion, gastritis and duodenitis.The risk factors of UGIB were previous history of peptic ulcer (P<0.01) and renal impairment (P<0.01). On the other side, PPI intake was a protective factor (P<0.05). The incidence of new-onset ACS was 1.44% (50/3 464) in PPI group, compared with 1.34% (76/5 654) in no PPI group (P>0.05). PPI use for the prevention of UGIB after PCI didn't increase the recurrence of ACS. The incidence of UGIB is 0.61% in ACS patients on dual antiplatelet therapy (aspirin and clopidogrel) for 1 year after PCI and falls year by year.Administration of PPI after PCI protects patients from UGIB, especially in those with precious history of peptic ulcer and renal impairment.

Gastrointestinal Bleeding in Acute Ischemic Stroke: Recent Trends from the Fukuoka Stroke Registry

Background: Gastrointestinal (GI) hemorrhage is a potentially serious complication of acute stroke, but its incidence appears to be decreasing. The aim of this study was to elucidate the etiology of GI bleeding and its impact on clinical outcomes in patients with acute ischemic stroke in recent years. Methods: Using the database of the Fukuoka Stroke Registry, 6,529 patients with acute ischemic stroke registered between June 2007 and December 2012 were included in this study. We recorded clinical data including any previous history of peptic ulcer, prestroke drug history including the use of antiplatelets, anticoagulants, steroids and nonsteroidal anti-inflammatory drugs (NSAIDs), and poststroke treatment with suppressing gastric acidity. GI bleeding was defined as any episode of hematemesis or melena on admission or during hospitalization. The cause and origin of bleeding were diagnosed endoscopically. Logistic regression analysis was used to identify risk factors for GI bleeding and its influence on deteriorating neurologic function, death, and poor outcome. Results: GI bleeding occurred in 89 patients (1.4%) under the condition that 66% of the total patients received acid-suppressing agents after admission. Multivariate analysis revealed that GI bleeding was associated with the absence of dyslipidemia (p = 0.03), a previous history of peptic ulcer (p < 0.001), and the severity of baseline neurologic deficit (p = 0.002) but not with antiplatelet drugs, anticoagulants, and NSAIDs. The source was the upper GI tract in 51% of the cases; causes included peptic ulceration (28%) and malignancies (12%), and other or unidentified causes accounted for 60%. GI bleeding mostly occurred within 1 week after stroke onset. Hemoglobin concentration fell by a median value of 2.5 g/dl in patients with GI bleeding. Among them, 28 patients underwent blood transfusion (31.5%). After adjustment for confounding factors, GI bleeding was independently associated with neurologic deterioration (OR 3.9, 95% CI 2.3-6.6, p < 0.001), in-hospital death (OR 6.1, 95% CI 3.1-12.1, p < 0.001), and poor outcome at 3 months (OR 6.8, 95% CI 3.7-12.7, p < 0.001). These associations were significant irrespective of whether patients underwent red blood cell transfusion. Conclusions: GI bleeding infrequently occurred in patients with acute ischemic stroke, which was mostly due to etiologies other than peptic ulcer. GI bleeding was associated with poor clinical outcomes including neurologic deterioration, in-hospital mortality, and poor functional outcome.

RISK FACTORS EFFECTING ON BLEEDING EVENTS IN PATIENTS WITH ACUTE ST-SEGMENT ELEVATION

ObjectivesTO search for risk factors influencing bleeding events in acute ST segment elevation myocardial infarction undergoing emergency PCI.MethodsThis study included 227 patients with acute ST segment elevation myocardial infarction undergoing...

Guidelines of Prevention and Treatment for NSAID-related Peptic Ulcers

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used medications in Korea. Gastrointestinal toxicity, including peptic ulcer, is a common adverse effect of NSAIDs. Risk factors for NSAID-related peptic ulcer include a previous history of peptic ulcer, advanced age, high dose, concomitant use of corticosteroids, anticoagulants, other NSAIDs including low-dose aspirin. Preventive measure(s), such as COX-2 inhibitor, proton pump inhibitor or misoprostrol, should be done for patients requiring NSAID therapy who have high-risk factor(s) for peptic ulcer. Low dose aspirin also increases the risk of peptic ulcer, so preventive measure(s) should be done for high-risk patients. The eradication of Helicobacter pylori is recommended for high-risk NSAID-users. Treatment strategies for peptic ulcers in NSAID users are mostly the same for peptic ulcers in NSAID non-users.

高齢者における急性消化管出血とその問題点

Acute massive gastrointestinal bleeding appears to be becoming more frequent and complex in elderly patients with increasing longevity and a variety of diseases. because of long-term medication such as anti-thrombotic agents (ATA) for the prevention of cardiovascular diseases, anti-dementia drugs for the treatment of dementia, with increasing longevity and a variety of diseases. We, therefore, conducted a study to clarify these problems from a clinical view point in geriatric medicine. The bleeding sites and the causes were studied in 85 consecutive patients with melena, hematemesis or acute blood loss, on the basis of clinical and emergency endoscopic findings. The patients were aged 66 to 95 (40 men and 45 women), and the underlying diseases were mainly cerebral infarction in the chronic phase, osteoarthropathy, atrial fibrillation, and dementia. Ten patients had a previous history of peptic ulcer. As initial symptoms, melena, hematemesis and acute anemia were seen in 49, 18 and 18 patients, respectively. Based on assessable endoscopic findings n=83), the bleeding sites were a gastroduodenal ulcer, reflux esophagitis/acute gastric mucosal lesion, colon diverticulum, or alimentary tract cancers in 43.4%, 13.2%, 16.9%, and 16.9%, respectively. A total of 75 patients were treated with some medications (on average 5.3 kinds of medication per patient). Non-steroidal anti-inflammatory drugs (NSAIDs) and/or ATA were common in 63.5% of 85 patients; particularly two thirds of the patients with hemorrhagic gastroduodenal ulcer had used non-aspirin NSAIDs for treatment of osteoarthropathy or acute upper respiratory inflammation, and/or low-dose aspirin for prevention of vascular events. Patients taking ATA over a long period had bleeding from various sites. Steroids, acetylcholinesterase inhibitor (AchEI), selective serotonin-reuptake inhibitor (SSRI), and bisphosphonates were taken by 5, 9, 3 and 3 patients, respectively, frequently in combination with NSAIDs or ATA. Cerebral infarction occurred in 3 of 38 patients after withdrawal of ATA. AchEI, SSRI and bisphosphonates, a newly developed group of drugs, have become widely available as geriatric medication. However, it appears that the incidence of drug-related gastrointestinal bleeding is extremely high not only in patients who underwent long-term treatment with NSAIDs or ATA, but also in patients treated chronically with AchEI, SSRI or bisphosphonates in combination with occasional use of NSAIDs. Therefore, to manage elderly patients safely, it is necessary to clarify both the drug and previous histories and consider NSAIDs use with caution even when they are indicated.

T1066 Risk of Upper Gastrointestinal Complications (UGIC) in Patients with a Previous History of Peptic Ulcer

T1066 Risk of Upper Gastrointestinal Complications (UGIC) in Patients with a Previous History of Peptic Ulcer

Risk of further ulcer complications after an episode of peptic ulcer bleeding.

To identify the risk factors for developing recurrent ulcer complications after recovery from an episode of peptic ulcer bleeding 611 patients admitted with peptic ulcer bleeding were studied. Some 557 (91 per cent) were discharged without operation. A total of 22 patients were lost to follow-up and five were excluded as maintenance H2 blockers were required. Of the remaining 530 patients at risk, 169 (32 per cent) developed another complication (166 bleeding, three perforations) over a median follow-up period of 36 months. Patients with duodenal ulcers at the time of bleeding, previous history of peptic ulcer, previous bleeding, history of dyspepsia longer than 3 months, and a short interval between previous ulcer complications and the index bleed were more likely to develop further complications. Sex, age, smoking, coexisting illness, non-steroidal anti-inflammatory drugs intake and time taken to achieve ulcer healing had no predictive value.

Sekundär- und Primärprophylaxe der ASS-/NSAR-Gastropathie: Eine Übersicht anhand vier klinischer Szenarien

Based on current references four clinical scenarios were discussed and different management strategies were compared for secondary and primary prophylaxis of ulcer or peptic ulcer bleeding under continuous therapy with non-steroidal antiinflammatory drugs (NSAID) or low-dose-aspirin, for H.pylori-positive and H.pylori-negative patients. Used as secondary prophylaxis eradication alone is insufficient in preventing recurrent peptic ulcer or recurrent ulcer bleeding for H.pylori-positive patients who continue to take unselective NSAIDs. Maintenance therapy with PPIs or switching from nonselective NSAID to COX-2-inhibitors is required after eradication of H.pylori or primary H.pylori-negative patients. Further evaluation is needed of what kind of secondary prophylaxis - maintenance therapy with PPI or switching to COX-2-inhibitor - is more (cost-)effective. It is sufficient to use eradication of H.pylori alone as secondary prophylaxis in preventing recurrent peptic ulcer or recurrent ulcer bleeding for H.pylori-positive patients, who continue to take low-dose-aspirin. Maintenance therapy with PPI is not generally required. However it can be considered for patients with increased risk for gastrointestinal complications (previous history of peptic ulcer, age over 65 years, concomitant use of corticosteroids, anticoagulants or individual NSAID with higher risk for gastrointestinal complications, serious cardiovascular disease). Switching from low-dose-aspirin to clopidogrel is not required. Used as primary prophylaxis in preventing peptic ulcer or ulcer bleeding before starting long-term therapy with NSAIDs, COX-2-inhibitors or unselective NSAIDs concomitant with PPIs are recommended for patients with increased risk for gastrointestinal complications. Patients starting long-term therapy with unselective NSAIDs should be screened for H.pylori and eradicated. There are no valid data supporting screening for H.pylori and eradication for patients starting long-term therapy with low-dose-aspirin. Further studies are needed to evaluate a possible benefit for patients with increased risk for gastrointestinal complications.

Significant factors associated with fatal outcome in emergency open surgery for perforated peptic ulcer.

To evaluate the main factors associated with mortality in patients undergoing surgery for perforated peptic ulcer referred to an academic department of general surgery in a large southern Italian city. One hundred and forty-nine consecutive patients (M:F ratio=110:39, mean age 52 yrs, range 16-95) with peptic ulcer disease were investigated for clinical history (including age, sex, previous history of peptic ulcer, associated diseases, delayed abdominal surgery, ulcer site, operation type, shock on admission, postoperative general complications, and intra-abdominal and/or wound infections), serum analyses and radiological findings. The overall mortality rate was 4.0%. Among all factors, an age above 65 years, one or more associated diseases, delayed abdominal surgery, shock on admission, postoperative abdominal complications and/or wound infections, were significantly associated (chi2) with increased mortality in patients undergoing surgery (0.0001<P<0.03). Factors such as concomitant diseases, shock on admission, delayed surgery, and postoperative abdominal and wound infections are significantly associated with fatal outcomes and need careful evaluation within the general workup of patients admitted for perforated peptic ulcer.

Age-related mortality in patients treated endoscopically for bleeding peptic ulcer

Before the widespread use of endoscopic therapy, mortality from peptic ulcer hemorrhage was highest in elderly patients, and many deaths in this group were a consequence of postoperative complications. Endoscopic intervention greatly reduces the need for an emergency surgical operation, and consequently increasing age may no longer be a risk factor for death from bleeding ulcer. To examine this hypothesis, the outcome of 326 patients undergoing endoscopic therapy for bleeding peptic ulcer was related to age. One hundred two patients were less than 60 years of age (group I), 116 were 61 to 74 years of age (group II), and 108 were older than 75 years (group III). More group III patients were women ( p < .0001) and were receiving nonsteroidal anti-inflammatory drugs ( p < .0001). Associated concomitant diseases were significantly more common in group II and group III patients ( p < .001). Forty-nine (45%) group III patients bled from gastric ulcers. More of group II patients were receiving anticoagulant drugs ( p < .005). A previous history of peptic ulcer was most common in group I ( p < .005), and duodenal ulcer was usually the cause of bleeding in this group. The three groups were well matched in terms of endoscopic stigmata (active bleeding and nonbleeding vessel), admission hemoglobin concentration, the presence of shock, and total transfusion requirements. Endoscopic therapy (injection or heater probe) was possible in 95% of all patients. The need for surgical intervention tended to be lowest in group I (11%, 19%, and 18%), whereas hospital mortality (3%, 6%, and 5%) was very similar. In this large group of unselected patients with major peptic ulcer bleeding, age did not significantly influence response to endoscopic therapy or hospital mortality. (Gastrointest Endosc 1995;41:557-60.)

Gastro-duodenal injury associated with intake of 100-325 mg aspirin daily.

During the year 1991, 43 patients with upper gastrointestinal bleeding and one with severe epigastric pain associated with intake of non-steroidal anti-inflammatory drugs were admitted for emergency endoscopy to our unit. Fourteen patients (33%) had been treated with 100-325 mg aspirin daily, 11 of them for at least one year. The mean age of this group was 71. Only two patients had a previous history of peptic ulcer. Five patients used anticoagulants or antiplatelet drugs concomitantly with aspirin. The endoscopic diagnosis of the sources of bleeding was erosive gastritis in eight patients, gastric ulcer in four, duodenal ulcer in five and oesophageal ulcer in one. Our results support findings by other groups, showing that doses of aspirin as low as 75 mg daily should be used in the management of elderly patients with thrombo-embolic disease.

Is Helicobacter pylori the cause of dyspepsia?

To determine the association between infection with Helicobacter pylori and dyspepsia. Cross sectional study of dyspeptic subjects and age and sex matched controls identified by a questionnaire survey of all inhabitants aged 20-69. (Endoscopy, histological examination, and microbiological examinations of biopsies from the gastric mucosa were performed blind.) Population based survey in Sørreisa, Norway. All 782 dyspeptic subjects (excluding those with a previous history of peptic ulcer, gall stones or kidney stones, and coronary heart disease) and controls were offered an endoscopy, of whom 309 dyspeptic subjects and 310 controls attended. Prevalences of endoscopic and histological diagnoses and of cultures positive for H pylori. A high prevalence of positive cultures, increasing with age, was found in both dyspeptic subjects (48%) and non-dyspeptic controls (36%) (p = 0.004). Positive cultures in both dyspeptic subjects and controls were strongly associated with histological gastritis (70%, 95% confidence interval 65.5 to 85.3; 60%, 52.7 to 67.7, respectively) and peptic ulcer (92%, 61.5 to 99.8; 64.1, 9.4 to 99.2, respectively). Only 3% of subjects with a histologically non-inflamed gastric mucosa had this infection (dyspeptic subjects 2%, 0.2 to 7.0; controls 4%; 1.2 to 8.8). The relation between dyspeptic symptoms and H pylori is dubious; H pylori seems to have a pathogenetic role in gastritis and may be a contributing factor but not a cause of peptic ulcer.

Peptic ulcer among allergic patients on long-term triamcinolone therapy

W ITH the increased use of adrenal corticosteroids during the past few years, there have appeared many reports of their undesirable side effects. One of the most serious has been peptic ulceration, with or without perforation or hemorrhage13 ?. 4-7 This has been a deterring factor in the use of these agents, especially in patients with a previous history of peptic ulcer. There have been few published report+ 3 of routino serial x-rays of t,htl upper gastrointestinal tract of patients who were being maintained on longterm corticosteroid therapy. It is the purpose of this study to determine the incidence of pept.ic ulccrat’ion in a group of allergic patients maintained on triamcinolona -for a long period of time.

Recurrent gastric ulcer incident to cortisone therapy.

While the occurrence of peptic ulceration of the stomach or duodenum due to adrenocortical preparations may be controversial, many reports in the literature would seem to substantiate the possibility. In the case to be reported here a very large gastric ulcer developed during cortisone therapy and promptly healed upon discontinuance of the drug. The ulcer recurred upon resumption of cortisone, but again healed when the medication was stopped. Case Report A 62-year-old woman with angina and evidence of coronary insufficiency complained of severe pain in the left shoulder. This was treated with cortisone, 25 mg. three times daily, starting Nov. 17, 1953. The pain was moderately relieved and the drug was maintained. After three months, attempts to reduce the dosage were followed by a return of symptoms. Eleven months after the institution of cortisone therapy, on Oct. 27, 1954, a gastrointestinal examination, performed elsewhere, revealed no abnormal conditions. In February 1956, the patient complained of epigastric distress and weakness. On March 28, 1956, she was hospitalized. The red blood cell count was 2,740,000, hemoglobin, 86 gm. Roentgen examination, April 2, disclosed a large gastric ulcer (Fig. 1). Treatment consisted of an ulcer diet, antacids, and transfusions. Cortisone was at first reduced to 25 mg. every other day and then discontinued, April 11. A repeat examination of the upper gastrointestinal tract on April 16 showed a marked reduction in the size of the ulcer (Fig. 2). The gastrointestinal symptoms completely subsided and another examination, May 17, showed the ulcer to be healed (Fig. 3). In September 1956, the patient's only complaint was a recurrence of shoulder pain. Prednisone, 0.75 mg., one tablet three times daily, produced a slight relief of symptoms, and on Sept. 11, 14, and 18, 100 mg. of cortisone were given intramuscularly. Each injection brought about complete relief of symptoms for twenty-four hours. On Sept. 26, pain in the abdomen again brought the patient to the hospital. A gastrointestinal examination disclosed a small gastric ulcer (1 cm. in diameter) at the site of the previous ulcer (Fig. 4). The cortisone was again stopped, whereupon the abdominal distress quickly subsided. A repeat examination on Nov. 8, 1956, revealed no evidence of ulcer (Fig. 5). Bollet et al. reported 3 cases of duodenal ulcer developing in patients under treatment with adrenocortical preparations (1). Among 141 arthritic patients receiving prolonged therapy with prednisone and prednisolone (2), Boland discovered 9 peptic ulcers. Hirschowitz et al. administered corticotropin experimentally to 6 students. In 1 of these, with a previous history of peptic ulcer, roentgen evidence of an acute exacerbation developed (3).